THE 



SCIENCE AND ART 



OF 



OBSTETRICS. 



BY 

SHELDON^ LEAVITT, M.D. 

Professor of Obstetrics, etc., in Hahnemann Medical College, and Clinical Pro- 
fessor of Midwifery in the Hahnemann Hospital, of Chicago ; Member 
of the American Institute of Homoeopathy ; Vice-President 
of the American Obstetrical Society, etc., etc. 



SECOND EDITION. 

Rewritten and Enlarged. 



CHICAGO : 

GBOSS & DELBRIDGE. 

1892. 

^ 



tf<V 



\iA 



My 



Copyright, 1892, 
By GROSS & DELBRIDGE- 



WERNER PTG. & LITHO. CO. 
AKRON, OHIO. 



PREFACE TO FIRST EDITION. 



I have been prompted to prepare this work by a conviction of 
the existence of an urgent demand for a treatise on the Science 
and Art of Obstetrics, in our School of Medicine, which should 
embody the advances recently made, and set forth the distinct- 
ive characters of our therapeutics in a rational and practical 
manner. 

Treatment in obstetrical practice in a great measure is me- 
chanical, and does not involve an extensive application of thera- 
peutical resources. Itis true that by the judicious use of homeo- 
pathic remedies labor may often be divested of its pathological 
features ; yet we must beware of expecting too much. We can- 
not reasonably hope to flex an extended foetal head, to amplify 
pelvic diameters, to reduce intra-uterine hydrocephalus, to 
effect version, or to arrest unavoidable hemorrhage by the 
most carefully affiliated remedy ; and the sooner the sphere of 
remedial action can be settled, the better for us and the princi- 
ples which w T e represent. The vantage-ground which we hold 
consists in our ability to reduce the number of cases demanding 
interference to a minimum, and to remove from the pathway 
of the parturient and puerperal woman all unnecessary 
difficulty and danger. 

In preparing a practical and reliable work of this kind, it is 
always found necessary to draw largel}^ from the writing and 
experience of others. In doing so, I have endeavored to award 
due recognition, and have sought to appropriate only the most 
valuable and practical truths. 

Though the matter has been prepared with the greatest care, 
important omissions and glaring errors will doubtless be dis- 
covered, on account of which, in advance, I implore the reader's 
most gracious forbearance. 

To numerous friends I would return my hearty thanks for 
the many aids and encouragements afforded ; and to my enter- 
prising publishers, for their excellent and energetic performance 
of the mechanical part of the work. 

SHELDON LEAVITT, M.D. 
Chicago, October 20, 1882. 

(iiij 



■Hn^aai 



PREFACE TO SECOND EDITION. 



The first edition of this work has been out of print for about 
three years, during which time I have economized the spare 
moments, gathered from busy days, in preparing for this edi- 
tion. So difficult has it been for me to find the necessary time, 
that, had it not been for the clamor of students, and the 
encouragement given by brother practitioners of sincerity and 
judgment, I fear the task would never have been finished. 
Whether the work, as now presented, will meet the needs, and 
fulfill the expectations, of those for whom it is intended, or not, 
they may rest assured that it represents a great amount of 
labor and earnest effort. 

When I came to review the first edition, more than three 
years ago, so many changes and additions were found needful 
that I at once resolved again to undertake the drudgery insepa- 
rable from a thorough revision of a work of this size. What 
is herein presented has been fully reduced to manuscript, and 
reset, hundreds of pages being displaced by entirely new mat- 
ter, and not a single page being reproduced without change. 
The size of the work has been augmented by upwards of one 
hundred pages, the therapeutic hints have been increased in 
number and perspicuity, recent methods have been intro- 
duced, imperfect cuts have been improved and some excellent 
ones added, until we are able to send out an entirely remodeled 
and reconstructed book. 

I have bestowed unusual pains on the index. Much medical 
lore lies hidden in text-books for want of suitable facilities for 
revealing it to the busy practitioner. It has been my aim to 
make every important subject readily accessible. Furthermore, 
the names of all authorities mentioned in the work have been 
indexed, together with the topic in connection with which they 
appear. 

I gratefully acknowledge special help in important details. 
The appendix consists of an excellent article on Antiseptic Mid- 
wifery prepared for the work by Prof. L. L. Danforth, M.D., of 
New York. The chapter on Puerperal Fever was written by 
T. Griswold Comstock, M.D., of St. Louis, and the therapeutics 

(v) 



vi Preface. 

of Syphilis During Pregnancy by Prof. T. S. Hoyne, M.D., of 
Chicago. Some valuable statistics and wise suggestions were 
furnished by George B. Peck, M.D., of Providence, and in pre- 
paring the index I Avas aided by Prof. F. H. Honberger, M.D., 
of Chicago. In addition to help so direct, rendered by these 
well-known gentlemen, I am indebted to Profs. Phil. Porter 
and George R. Southwick, and others, for valuable suggestions. 

Notwithstanding the great care taken in its preparation, 
I am painfully conscious of numerous defects which mar the 
book, some of them plainly traceable to my lack of proficiency 
in literary composition. There are doubtless many glaring 
omissions in the matter of therapeutics, while again some of 
my recommendations will not meet the approval of those who 
regard mere medication as abundantly adequate for all exi- 
gencies. 

In conclusion I reaffirm my implicit confidence in the efficacy 
of the indicated remedy for the correction of abnormal condi- 
tions which may reasonably be expected to respond to mere 
medication. 

SHELDON LEAVITT, M.D. 
148 Thirty-seventh Street, Chicago, 
May 1, 1S92. 



LIST OF ILLUSTRATIONS. 



Figure Page 

1. The Right Os Innominatum. (Outer Surface), 2 

2 The Right Os Innominatum. (Inner Surface), .... 3 

3. The Anterior Surface of the Sacrum, 5 

4. Section of the Symphysis Pubis, 7 

5 Section Through the Left Sacro-iliac Articulation, .... 8 

6. The Articulated Pelvis, 11 

7. Showing the Diameters of the Superior Strait, ..... 12 

8. Showing the Diameters of the Outlet 13 

9. Plane of Outlet, 15 

10. Horizontal Planes, . . . . 16 

11. Axis of Parturient Canal, 16 

12. Inner Surface of the Left Half of the Pelvis, 17 

13. Male Pelvis, 18 

14. Female Pelvis, 19 

15. Lateral View of Erectile Structures, 21 

16. Vulva of the Virgin, 22 

ic' [ Figures Showing Different Forms of Hymen 23 

19. Vascular Supply of Vulva, 25 

20. The Vagina, 27 

21. Section of Female Pelvis, 28 

22. Relations of Vagina, Perineum and Rectum, 30 

23. Muscles of the Perineum, 31 

24. Full View of External and Internal Generative Organs, . . .32 

25. Normal Position of the Uterus with Empty Bladder, ... 34 

26. Anterior View of Virgin Uterus, . . 35 

97 ) 

«o' - Median Section of Virgin Uterus, 37 

29. Muscular Fibers of Unimpregnated Uterus, . . . . .38 

30. External Muscular Fibers of the Uterus, 39 

31. Inner Muscular Fibers of the Uterus, 40 

32. Section Showing Glandular Structure of the Uterus, . . ' 42 

33. Arterial Vessels in a Uterus Ten Days After Delivery, . . .43 

34. Nerves of the Uterus, 44 

35. Uterus with Double Cavity and Slight Deviation of Form, . . 45 

36. Uterus Septus Bilocularis, 45 

37. Double Uterus and Vagina, 46 

38. Ovary and Fallopian Tube, 48 

39. Longitudinal Section of Ovary, 50 

40. Part of Vertical Section Through Ovary of Bitch, .... 5] 

41. Diagrammatic Section of Graafian Follicle, . . . . 52 

42. Uterine and Utero-ovarian Veins, 53 

43. Section of Pelvis Showing the Pyramidal Muscles 54 

(vii) 



■■HBU 



viii List of Illustrations. 

Figure Page 

44. Supernumerary Mammae, ..... 55 

45. Mammary Gland, ■ . . .56 

46. Spermatozoa, 62 

47. Bifurcation of the Tubal Canal, .'..,■ 63 

48. ) 

49. [ Successive Stages of Segmentation of the Yolk, .... 64 

50. ) 

51. External Surface of the Ovum, with A rea Germinativa, . . .65 

to" [ Progressive Development of the Ovum, ... .66 

54. Showing Amnio-chorial Pocket of False Waters, . - . .67 

55. Human Embryo at the Third Week, 68 

56. Formation of the Decidua Reflexa First Stage, . . . .69 

57. Formation of the Decidua Reflexa, completed, .... 69 

58. Flap of Decidua Reflexa Turned Down, Disclosing the Ovum, . . 70 

59. Placental Villus, Magnified 71 

60. Foetal Surface of the Placenta, 72 

61. Uterine Surface of the Placenta, 72 

go" [ Specimens of Placentae Succenturiatae, 73 

64. Section of Uterus and Placenta at Fifth Month, .... 74 

65. Ovum and Embryo, 76 

66. Ovum of Seven Weeks, . . 76 

67. Ovum at Five Months, . . .77 

68. Diagram of Foetal Circulation, 80 

69. The Vertex, 82 

70. Posterior View of the Cranium, . 82 

71. Lateral View of the Cranium with Indicated Diameters, . . 83 

72. Attitude of the Foetus in Utero, 85 

73. The Foetal Ovoid, 88 

tf4. Situation and Surroundings of the Foetus in Utero, ... 89 

75. Height of Cervix and Fundus at Different Weeks of Pregnancy, . 92 

76. Cervix at the Fourth Month of Pregnancy 93 

77. Cervix at Fifth Month of NPregnancy, . . . . . . .94 

78. Cervix at the Close of the Eighth Month, . . . . 94 

79. Cervix of Multipara who Died at the Eighth Month, . . .95 

80. Cervix at a Period Beyond the Seventh Month, .... 96 

81. Appearance of the Areola, . . .97 

82. Lateral View at the Sixth Month, 98 

83. Lateral View at the Ninth Month, 98 

84. Pendulous Abdomen, .......... 99 

85. Striae of Pregnancy, 100 

86. Tracing of Normal Pulse of a Pregnant Woman, . . . . 101 

87. Bimanual Examination in Pregnancy, 109 

88. Palpation of Foetal Trunk, 120 

89. Palpation of Foetal Cranium, 120 

90. Palpation of Foetal Cranium, 121 

91. Locations of the Foetal Heart-sounds, 122 

92. Location of Foetal Heart-sounds in First Position of the Vertex, . 123 

93. Location of Foetal Heart-sounds in First Position of the Face, . 123 



List of Illustrations. ix 

Figure Page 

94. Location of Fcetal Heart- sounds in First Position of the Breech, 123 

95. Location of Fcetal Heart-sounds in Dorso-anterior Position of Trans- 

verse Presentation, 123 

96. Location of Fcetal Heart-sounds in Twin Pregnancy, . . . 123 

97. Size of Uterus at Various Periods of Pregnancy, .... 133 

98. Abdominal Pregnancy, 141 

99. A Lithopsedion, 142 

100. Interstitial Pregnancy, . . 143 

101. Tubal Pregnancy, 144 

102. Tubal Pregnancy, 145 

103. Pregnancy in Rudimentary Horn of Uterus, 146 

104. Ovum with Imperfectly-developed Decidua Reflexa, . . . 161 

105. Uterus, with Basis of a Fibrinous Polypus After an Abortion, . 167 

106. The Ovum Forceps, 178 

107. Leavitt's Uterine Curette, 179 

108. Leavitt's Placenta Hook, 182 

109. Hypertrophied Decidua Laid Open : Ovum at the Fundus, . 186 

110. Hydatidiform Mole, . .189 

111. Hydatidiform Mole (Placental Origin), 189 

112. Fatty Degeneration of the Placenta, 194 

JJJ I Knots of the Umbilical Cord, .200 

115. Torsion of the Cord, .201 

116. Intra-uterine Amputations, 204 

117. Acephalic Foetus, 205 

118. Pygopagi, 207 

11Q ) 

IIq [• Monosomata, 207 

121. Relative Size and Inclination of the Uterus at the Close of Gesta- 

tion, 257 

122. Retroflexion of the Gravid Uterus, 258 

123. Soft Rubber Catheter, 260 

124. The Uterine Mucous Membrane, . .309 

125. Showing Various Stages of Dilatation, 321 

126. Section of a Frozen Body at the Termination of the First Stage of 

Labor, 322 

127. The Parturient Canal, 323 

128. Dilating Os with Protruding Membranes, 326 

129. Dilating Os with Protruding Membranes, 326 

130. Dilating Os with Protruding Membranes, 327 

131. Dilating Os with Protruding Membranes, 327 

132. Section Showing Foetus, Inclosed in its Membranes, with Expand- 

ing Os, 328 

133. Descending Head Dilating the Os, 329 

134. The Uterus and Parturient Canal, . 330 

135. Distension of the Perineum, 331 

136. Showing Movements of the Sacrum, 332 

137. Normal Mode of Separation and Expulsion of the Placenta, . 334 

138. Mode of Separation and Expulsion when Traction is Made on the 

Cord, 334 



■san 



x List of Illustrations. 

Figure Page 

139. The Vaginal Touch, 341 

il? I Showing the Difference in Involved Diameters Between Flexion 
14 2 \ an( i Extension of the Head, 353 

143. Method of Supporting the Perineum with the Woman in the 

Lateral Decubitus 356 

144. Method of Perineal Protection During Forceps Delivery, . . 360 

145. Distension and Threatened Rupture of Perineum, .... 362 

146. Showing Ligatures of the Umbilical Cord, and Point of Section, 364 

147. The Square Knot, 365 

148. Delivery of Placenta by Expression, 369 

149. Delivery of the Placenta by the Mixed Method, . . . .369 

150. Rotation of the Placenta During Delivery to Make the Trailing 

Membranes Stronger, 370 

151. Inversion of Placenta from Traction on the Cord, . . . 371 

152. Marginal presentation of the Placenta, .... . . 372 

153. Suturing Lacerated Perineum, 376 

154. Section Showing Suturing Completed, 377 

155. Allis' Ether Inhaler, 387 

156. Esmarch's Inhaler, 389 

157. First Position of the Vertex, 392 

158. Second Position of the Vertex, 392 

159. Third Position of the Vertex, 392 

160. Fourth Position of the Vertex, 392 

161. First Position of the Face, 393 

162. Second Position of the Face, ........ 393 

163. Third Position of the Face, . . 393 

164. Fourth Position of the Face, 393 

165. First Position of the Breech, . . . j 394 

166. Second Position of the Breech . 394 

167. Third Position of the Breech, 394 

168. Fourth Position of the Breech, 394 

169. Second Position of Footling Presentation, ..... 395 

170. Fourth Position of the Feet, ........ 395 

171. Third Position of Transverse, .... .' . . .395 

172. Second Position of Transverse, . . , . 396 

173. Fourth Position of Transverse, 396 

174. First Position of the Vertex, . 396 

175. First Position of the Breech, ........ 396 

176. Second Position of the Vertex, 397 

177. Second Position of the Breech, . . . . . .397 

178. First Position of the Vertex, . 404 

179. Showing Lateral Obliquity of the Head, 405 

180. Leverage Action of the Head, 406 

181. External Rotation of the Head, .407 

182. Head Approaching the Outlet in the First Position, . . .408 

183. Showing Various' Movements of the Head in First Position of the 

Vertex, . . .... 408 

184. Second Position of the Vertex, . . . . . . . 409 

185. Third Position of the Vertex, ........ 410 



List of Illustrations. xi 

Figure Page 

186. Fourth Position of the Vertex, 410 

187. Showing Proper Rotation of the Head in Fourth Position of the 

Vertex, 410 

188. Occipito-posterior Termination of Third Position of the Vertex, 412 

189. Outline of Foetal Head After an Ordinary Labor, .... 415 

190. Outline of Head Four Days After Birth, 415 

191. Form of Head After Difficult Vertex Labor, 416 

192. Face Presentation at the Outlet 419 

193. Engagement of the Head in Face Presentation, .... 420 

194. Showing Proper Rotation of the Head in Second Position of the 

Face, 421 

j^' [Diagrams Illustrating Schatz's Method of Converting Face into 

197 \ ^ er tex Presentations, 424 

. 425 

. 426 

. 428 

. -429 

. 430 

. 431 

. 432 

. 433 

. 434 

. 436 

. 437 



198. Mento-posterior Termination of Labor, . 

199. Outline of Head : Brow Presentation, . 
"200. Movements of the Breech in First Position, . 

201. Expulsion of the Trunk in Breech Presentation, 

202. Delivery of Posterior Arm in Head-last Cases, 

203. Third Position of the Breech, .... 

204. Delivery of the After-coming Head, 

205. The Forceps Applied to the After-coming Head, 

206. Shape of the Head in Breech Presentation, . 

207. Second Position of the Breech, .... 

208. Breech Raised Above the Brim of the Pelvis, 

209. Position of the Hands in Performing Vagino-abdominal Version, 438 

210. Method of Performing External Version After Displacement of 

the Breech, 439 

211. Position of the Foetus when Version is Complete, .... 440 

212. Dorso-anterior Position of the Foetus in Transverse Presentation, 445 

213. Dorso-posterior Position of the Foetus in Transverse Presentation, 445 

214. Transverse Presentation with Shoulder Wedged in the Brim, . 447 

215. Spontaneous Expulsion, . . . . 448 

216. Spontaneous Expulsion. Second Stage, . . . . 449 

217. Use of the Fillet with Running Noose, 452 

218. Cystocele Complicating Labor, 472 

219. Multiple Fibroid Developments on the Gravid Uterus, . . . 474 

220. Labor Impeded by Uterine Polypus, 475 

221. Labor Obstructed by Ovarian Tumor, 476 

222. Flattened (Rachitic) Pelvis, .. . . . . . .478 

223. Malacosteon Pelvis, . . 479 

224. Obliquely-distorted Pelvis, . . 480 

225. Flattening of the Sacrum, 481 

226. Exaggerated Sacral Curve, 481 

227. Robert's Pelvis, 482 

228. Spondylolisthetic Pelvis, 482 

229 Pelvic Exostosis, 483 

230. Manual Pelvimetry, 487 

231. ) Change of Cephalic Form, from Molding, in Difficult Head-last 

232. J Cases, .495 



HUH 



xii List of Illustrations. 

Figure Page 

233. Transverse Diameters of the Head as Viewed from Above, . 496 

234. Molding of Head at the Brim in Difficult Cases of Extraction After 

Version, 498 

235. Twins Lying Laterally, One Presenting by the Vertex and the 

Other by the Breech, 502 

236. Twins, One Anteriorly and the Other Posteriorly, .... 502 

237. Twins, the Inferior Presenting by the Breech, and the Other by 

the Shoulder, 503 

238. Twins, the Inferior Presenting by the Dorsum, and the Other by 

the Vertex, 503 

239. Twins, Both Lying Transversely, One Above and the Other Below, 504 

240. Head-locking, 505 

241. Head-locking, . . . 506 

242. Double Monster, 507 

243. Double Monster United Anteriorly, ■ . 508 

244. Pelvic Presentation with Hydrocephalus. Tapping through Spinal 
Canal, 511 

245. Mode of Perforating the Head in Pelvic Presentations, . . . 512 

246. Dorsal Displacement of the Arm, 513 

247. Varieties of Placental Attachments, 516 

248. Central Placenta Previa, . . 519 

249. T Bandage to Hold Tampon, 526 

250. Prolapse of the Umbilical Cord, 539 

251. Inclination of the Uterus, in the Dorsal Posture, Favoring Descent 

of the Cord into the Pelvis, 542 

252. Postural Treatment of Prolapse of the Cord, .... 543 

253. Manual Reposition of the Cord, 544 

254. Reposition of the Cord with Forceps, . . . . . . 545 

255. Bimanual Compression of the Uterus, 572 

256. Irregular Uterine (Hour-glass) Contraction, with Retention of the 

Placenta, 580 

257. Incipient Inversion, . 581 

258. Showing Commencement of Inversion at the Cervix, . . . 581 

259. Complete Inversion of the Uterus, . . . . . . . 583 

260. Schultze's Method with Asphyxia, . 588 

261. Schultze's Method with Asphyxia, 589 

9gg' j- Combined Method of Turning, . .598 

264. Combined Method of Turning, 599 

5 fifi ' t Internal Podalic Version, ........ 600 

^oo' - Internal Podalic Version, 601 

269. Use of Running Noose on the Foot, . . . . . 602 

270. Turning by the Noose, 603 

271. Chamberlen's Forceps, 606 

272. Stone's Short Forceps, 606 

273. Knox's Short Forceps, ... ..... 606 

274. Reamy's Forceps, ........... 607 

275. Comstock's Forceps, . . . . . - . - . . 608 



List of Illustrations. xiii 

Figure Page 

276. Leavitt's Forceps, ' . . . .608 

277. Tarnier's Axis-traction Forceps, 609 

278. Leavitt's Forceps Applied to the Head Above the Brim, showing 

how Traction can be Made in the Axis of the Plane of the 
Pelvic Brim, 609 

279. The Forceps at the Brim, by the Pelvic Mode, .... 610 

280. Introduction of the First Blade, 613 

281. Imperfect Seizure of the Head Above the Brim, .... 614 

282. Showing How the Head is Usually Seized in the Cephalic Applica- 

tion, 615 

283. Folding Yectis, 620 

284. Taylor's Blunt Hook, 621 

285. Soft Eubber Catheter, ......... 622 

286. Manner of Holding Catheter, . . . . . . . .623 

287. Thomas's Perforator, .... „ , .... 624 

288. Blot's Perforator, 624 

289. Blunt Hook and Crotchet, . .625 

290. Thomas's Craniotomy Forceps, 625 

291. Use of Craniotomy Forceps, 626 

292. Simpson's Cranioclast, . .627 

293. Lusk's Cephalotribe, 628 

294. Mode of Using the Decapitating Hook, 630 

295. Applying the Chain of the Ecraseur for Decapitation, . . 631 

296. Decapitation of the Foetus with the Ecraseur, 631 

297. Manual Delivery of the Head After Decapitation, . . . 632 

298. Delivery of the Child in Cesarean Section, 637 

299. Kemoval of the Secundines in Cesarean Section, . . . 638 

300. Showing Uterine Incision Closed with Sutures, . . . .640 

301. ) Diagrams to Show the Placing of Sutures in the Uterine 

302. j Wound After Cesarean Section, 641 

303. Pulse in Primigravida, . . 650 

304. Pulse During Expulsion, 650 

305. Pulse Immediately After Delivery, 651 

306. Pulse a Few Hours After Delivery in a Patient who had Suffered 

a Profuse but not Dangerous Hemorrhage, . . • 651 

307. Pulse Seven Days After Delivery, 652 

308. Pulse of Non-pregnant Woman in Health, 652 

309. Pulse of Same Woman Under Extreme Nervous Excitement, . 653 

310. The Clinical Thermometer, 655 

311. Diagram Showing Temperature and Pulse Curves in a Normal 

Case, 656 

312. Uterus of a Multipara at Term, . 657 

313. Inner Surface of Uterus After Delivery, 658 

314. Section of Uterine Sinus from the Placental Site Nine Weeks After 

Delivery, ............ 662 



l»BH 



CONTENTS. 

PART I. 
ANATOMY AND PHYSIOLOGY OF THE FEMALE PELVIC ORGANS 



CHAPTER I. 

ANATOMY OF THE PELVIS, ^1 

Component Parts of the Pelvis — The Os Innominatum — The Os 
Ilium — The Os Ischium — The Os Pubis — The Os Sacrum — The Os 

Coccyx. 

CHAPTER II. 

THE ARTICULATIONS AND GENERAL CHARACTERS OF 
THE PELVIS, 7 

The Symphysis Pubis — The Sacro-iliac Synchondroses — Mechan- 
ical Relations of the Sacrum — The Sacro-coccygeal Joint — 
The Ligaments of the Pelvis — The Pelvis as a Whole— Dimen- 
sions of the Pelvis — Inclination of the Pelvis — Planes of 
the Pelvis — Axis of the Parturient Canal — The Inclined 
Planes — Male and Female Pelves. 

CHAPTER III. 

THE FEMALE EXTERNAL GENERATIVE ORGANS, ... 20 

The Vulva— The Labia Minori— The Clitoris— The Vestibule— The 
Vaginal Orifice — The Hymen — The Fossa Navicularis — The Secretory 
Apparatus — The Bulbi Vestibuli — The Vagina — The Perineum. 

CHAPTER IV. 

THE FEMALE INTERNAL GENERATIVE ORGANS, ... 34 

The Uterus — The Uterine Ligaments — The Uterine Cavity — Structure 
of the Uterus. — Abnormalities of the Uterus. 

CHAPTER Y. 

THE FEMALE INTERNAL GENERATIVE ORGANS— Continued, . 48 
The Fallopian Tubes— The Ovaries — The Graafian Follicles — Ves- 
sels and Nerves of the Ovary — The Intra-pelvic Muscles — The 
Mammary Glands. 

(xv) 



xvi Contents. 

PAET II. 
PREGNANCY 



CHAPTER I. 

IMPREGNATION AND DEVELOPMENT OF THE OVUM, . . 57 
The Corpus Luteum of Menstruation — The Corpus Luteum of 
Pregnancy — The Migration of the Ovum — Fecundation — Course 
of Spermatozoa to Point of Fecundation — Changes in the 
Ovum After Fecundation — Sources of Nourishment — The 
Chorion — The Allantois — The Decidua — The Placenta— The 
Umbilical Cord — The Liquor Amnii. 

CHAPTER II. 

DEVELOPMENT OF THE EMBRYO AND FCETUS, .... 76 
In the First Month — Second Month — Third Month — Fourth 
Month — Fifth Month — Sixth Month — Seventh Month — Eighth 
Month — Ninth Month — Circulation of the Blood in the Fcetus 
— The Cranium — Attitude, Presentation and Position of the 
Fcetus — Presentations and their Causes — Position. 

CHAPTER III. 

CHANGES IN THE MATERNAL ORGANISM WROUGHT BY 

PREGNANCY, 90 

Uterine Changes — Change in Situation — Inclination of its Longitudi- 
nal Axis — Changes of Cervical Position — Changes in the Size and 
Texture of the Cervix Uteri — Vaginal and Vulvar Changes — 
Changes in the Mammae — Changes in the Uterine Appendages — 
Abdominal Changes — Disturbance of Neighboring Organs 
from Pressure — Changes in the Blood — Miscellaneous 
Changes — The Permanent Changes. 

CHAPTER IV. 

THE DIAGNOSIS OF PREGNANCY, 104 

Classification of the Signs — Subjective Symptoms — History of the 
Case — The Menstrual Flow — Morning Sickness — Unreliability of Sub- 
jective Symptoms — Objective Symptoms — Inspection — Palpation — 
Percussion — Auscultation — Differential Diagnosis— Dia gnosis of 
Fcetal Death — Proofs of Former Pregnancy and Labor — Diag- 
nosis of Fcetal Presentation and Position by Abdominal Aus- 
cultation — Diagnosis of Twin Pregnancy through Ausculta- 
tion — Diagnosis of Sex from Rapidity of the Fcetal Heart. 



Contents. xvii 



CHAPTER V. 

THE DURATION OF PREGNANCY, . . . 127 

The Minimum — The Maximum — Prediction of Date of Confinement 
— The Date of Quickening — Prediction of Time of Labor from 
Size of Uterus. 

CHAPTER VI. 

PSEUDOCYESIS, • . . . • . .135 

Conditions of Development — Etiology — Symptoms — Diagnosis — 
Treatment. 

CHAPTER VII. 

EXTRA-UTERINE PREGNANCY, 140 

Ovarian Pregnancy — False Ovarian, or Tubu-Ovarian, Preg- 
nancy — Abdominal Pregnancy — Interstitial Pregnancy — 
Tubal Pregnancy — Pregnancy in a Rudimentary Horn of the 
Uterus — Rarer Varieties — Symptoms of Extra-uterine Preg- 
nancy — Termination — Diagnosis — Treatment — Cases of Recent 
Impregnation — Puncture of the Sac — Injections into the Sac — Elec- 
tricity — Laparotomy — Treatment After Rupture — Cases of Advanced 
Gestation, the Fcetus Still Living — Operation through the Vagina — 
Cases of Gestation Prolonged After Death of the Fcetus — Missed 
Labor — Treatment. 

CHAPTER VIII. 
PREMATURE EXPULSION OF THE OVUM, 159 

Causes of Abortion — Predisposing — Ovulary — Maternal — Immediate 
— Symptoms — Incomplete — Expulsion of One Foetus in Twin 
Pregnancy — Diagnosis — Prognosis — Treatment — Preventive — 
Promotive — Neglected Cases. 

CHAPTER IX. 

PATHOLOGY OF THE OVUM AND DECIDUvE, 185 

Endometritis — Pathology of the Chorion — Causes of Hydatidiform 
Degeneration — Symptoms and Course — Diagnosis — Prognosis — Treat- 
ment — The Placenta^— Size — Situation — Degenerations and Neiv 
Formations — Syphilis of the Placenta — Apoplexy and Inflammation 
of the Placenta— Hydramnios — Signs and Symptoms — Diagnosis — 
Termination — Prognosis — Effect on Labor — Treatment — Deficiency 
of the Amniotic Fluid — Anomalies of the Amniotic Fluid — 
Pathology of the Cord — Torsion — Coiling — Cysts — Hernia — Cal- 
careous Deposits — Stenosis of the Vessels — -Anomalous Insertion — 
Pathology of the Fcetus — Inflammations — Fevers — Syphilis — 
Hydrocephalus — Pleurisy, etc. — Intra-uterine Amputations — Mon- 
strosities — Death and Retention of the Fcetus — Putrefaction — Mummi- 
fication — Maceration — Moles. 



■B^H 



xviii Contents. 



CHAPTER X. 

DISEASES AND ACCIDENTS OF PREGNANCY, . . . . 212 

The Hygiene of Pregnancy — Derangements of the Digestive 
System — Ptyalism — Pruritus — Insomnia — Anaemia — Albumi- 
nuria — Causes — Symptoms — Effects — Prognosis — Conclusions — 
Treatment — The Milk Diet — Therapeutics — Chorea — Hysteria — 
Paralysis — Syncope — Painful Mammj: — Leucorrhoj; a — Odon- 
talgia — Cramps — Traumatic Complications — Constipation — 
Diarrhcea — Vesical Irritation — Cough — Dyspnoea — Hemor- 
rhoids. 

CHAPTER XI. 

THE DISEASES OF PREGNANCY— Continued, 257 

Displacements of the Grayid Uterus — Anteversions and Ante- 
flexions — Retroversions — Retroflexions — Prolapse — Cardiac Diseases 
— Eruptive Fevers — Variola — Scarlatina — Continued Fevers — 
Typhoid — Malarial — Pneumonia — Phthisis — Erysipelas — Syphi- 
lis — Uterine Rheumatism — Insanity of Pregnancy — Etiology — 
Diagnosis — Prognosis — Treatment — Eclampsia — Frequency — Eti- 
ology — Pathological Anatomy — Prodromata — The Seizure — Diagnosis 
Occurrence and Mortality — Treatment. 



PAET III. 
LABOR. 



CHAPTER I. 

CAUSES AND CHARACTER OF LABOR, . . . . . . 307 

The Causes of Labor — The Expelling Powers. 

CHAPTER II. 

CLINICAL COURSE A*ND PHENOMENA OF LABOR, . . .318 
The Stages of Labor — The First Stage — Tt?e Mechanism of Dilatation 
— Rupture of the Membranes— The Second Stage — Movements of the 
Pelvic Articulations — The Third Stage — Duration of Labor — 
The Hour of Labor. 

CHAPTER III. 

THE MANAGEMENT OF NORMAL LABOR, 337 

Preliminary Arrangements — Armamentarium — How to Approach 
the Patient — The Examination — Has Labor Begun ? — False 
Labor Pains — Patient's Bed and Dress — Position op the 



Contents. xix 

Woman — First Stage — Bearing Down — Treatment of the Mem- 
branes — The Second Stage — Bearing Efforts — The Use of Anesthet- 
ics — Indications for Interference — The Prevention of Laceration — 
Frequency of Laceration — Extent of Rupture — Treatment of the 
Cord — Early and Late Ligation — The Third Stage — Delivery of 
the Placenta by Expression — The Mixed Method — Manual Compres- 
sion of the Uterus — Immediate Repair of Lacerations — Post-partum 
Care of the Woman — The Binder — General Therapeutics of Labor. 

CHAPTER IY. 

USE OF ANESTHETICS IN MIDWIFERY PRACTICE, . . .383 
Obstetrical Anesthesia — Surgical Anesthesia — Rules for Ad- 
ministering Anesthetics. 

CHAPTER V. 

THE VARIOUS POSITIONS OF THE FCETUS, . ... . .390 

The Theory of Classification — The Basis of Classification — 
The Relative Frequency of Positions — Points of Coincidence 
Between the Various Positions. 

CHAPTER VI. 

VERTEX PRESENTATIONS, 401 

Relative Frequency of Vertex Presentations — Mechanism of 
Labor in the First Position — Expulsion of the Trunk — Me- 
chanism of the Second Position — Mechanism of Occipito-pos- 
terior Positions — Caput Succedaneum — Configurations of the 
Head in Vertex Presentation — Diagnosis of Positions, etc. 

CHAPTER VII. 

FACE PRESENTATIONS, .417 

Relative Frequency of Positions — Form of Cranium in Face 
Presentation — Prognosis — The Second Position-^Third and 
Fourth Positions — Conversion of Face into Vertex Presenta- 
tion — Management when the Face does not Enter the Brim — 
Persistent Mento-posterior Positions — Brow Presentation. 

CHAPTER VIII. 

PELVIC PRESENTATIONS, 427 

Frequency — Prognosis — Causes of Infantile Mortality — Etio- 
logy of Pelvic Presentation — Mechanism of Breech Presenta- 
tion in First and Second Positions — Mechanism of Breech ■ 
Presentation in the Third and Fourth Positions — Footling 
Presentation — Configuration of the Head in Pelvic Delivery 
— Management of Pelvic Presentations — Expulsion of the 
Trunk — Extraction of the Head. 



^mm 



xx Contents. 

CHAPTER IX. 

TRANSVERSE PRESENTATION 442 

Frequency — Causes — Diagnosis — Prognosis — Treatment — Com- 
plex Presentations. 

CHAPTER X. 

PRECIPITATE LABOR, . . . . .454 

WEAK LABOR 455 

Causes — Symptoms — Treatment — The Forceps in Inert Labor — 
Treatment of Third Stage Complicated by Inertia. 

CHAPTER XL 

PARTURIENT ANOMALIES REFERABLE TO THE MATERNAL 

SOFT PARTS, 463 

Rigidity op the Cervix — Symptoms — Treatment — Uterine Tetanoid 
Constriction — Diagnosis — Treatment — Atresia op the External 
Uterine Orifice — Complete Obliteration of the Cervical 
Canal — Tumefaction and Incarceration of the Anterior Lip — 
Carcinoma of the Cervix — Thrombus of the Vagina and 
Vulva — Cystocele — Rectocele — Vesical Calculus — Diffuse 
Swelling — Unyielding Hymen — Uterine Polypi — Ovarian 
Tumors — Rigidity of the Perineum. 

CHAPTER XII. 

PARTURIENT ANOMALIES REFERABLE TO THE MATERNAL 

OSSEOUS STRUCTURES, 478 

Deformities of the Pelvis — Large Pelvis — Symmetrically-contracted 
Pelvis — Flattened Pelvis — Flattened, Generally Contracted Pelvis — 
Irregular Rachitic and Malacosteon Pelvis — Oblique Oval Pelvis — Flat- 
tening of the Pelvis — Exaggerated Curve of the Sacrum — Funnel-shaped 
Pelvis — Infantile Pelvis — Deformities from Spinal Curvature — The 
Anchylotic, Transversely-contracted Pelvis — Spondylolisthetic Pelvis 
— Osteosarcoma and Exostosis — Other Osseous Tumors and Projec- 
tions — The Chief Causes of Pelvic Deformities — Diagnosis — Influence 
of Pelvic Contraction on the Uterus During Pregnancy — Influence of 
Pelvic Contraction on Fatal Presentation — Influence of Pelvic Con- 
traction on Labor-pains — Influence of Pelvic Contraction on the First 
Stage of Labor— Effect of Pressure on the Soft Pelvic Tissues— Effect 
of Pressure on the Child's Head — Prognosis — Treatment — Induction 
of Abortion in Extreme Deformity — Induction of Premature Labor in 
Deformed Pelvis — When is Interference During Labor Advisable? — 
Traction Force Applied After Version, with Results — The Forceps 
and Version Compared — Cases in which a Full-term Living Child 
Cannot be Born, but Delivery through the Natural Passages is Ad- 
visable — Cases wherein Extraction Through the Natural Passages 
Appears to be Impossible. 



Contents. xxi 



CHAPTER XIII. 

PARTURIENT ANOMALIES REFERABLE TO THE FCETUS OR ITS 

APPENDAGES, 501 

Plural Pregnancy — Arrangement of the Membranes — Conditions At- 
tending Intra-uterine Development — Labor in Plural Pregnancy — 
Management of the First Birth — Delay after Birth of First Child — 
Locked Twins — Double Monsters — Intra-uterine Hydrocephalus 
Hydrothorax — Ascites and Vesical Distension — Other Ab- 
normalities — Large Foetuses — Dorsal Displacement of the Arm. 

CHAPTER XIV. 

PARTURIENT ANOMALIES REFERABLE TO THE FCETUS OR 

ITS APPENDAGES— Continued, 515 

Unavoidable Hemorrhage — Placenta Previa — Varieties — Fre- 
quency — Causes of the Hemorrhage — Symptoms — Diagnosis — Progno- 
sis — Treatment — Treatment Before Moderate Dilatation of the Os — 
Treatment After Moderate Dilatation of the Os — Prolapse of the 
Funis — Frequency — Prognosis — Causes — Signs — Treatment — Acci- 
dental Hemorrhage — Lts Character — Causes — Varieties — Symp- 
toms — Prognosis — Treatment. 

CHAPTER XV. 

OTHER PARTURIENT ANOMALIES ARISING IN THE FIRST 

AND SECOND STAGES OF LABOR, "552 

Rupture of the Uterus — Time — Cause — Symptoms — Prognosis — 
Treatment — Laceration of the Cervix— Lacerations of the Vagina. 

CHAPTER XVI. 

PARTURIENT ANOMALIES ARISING IN THE THIRD STAGE OF 

LABOR, . 562 

Post-partum Hemorrhage — Premonitory Symptoms — General Symp- 
toms — Secondary Hemorrhage — Prognosis — Treatment. 

CHAPTER XVII. 

PARTURIENT ANOMALIES ARISING IN THE THIRD STAGE OF 

LABOR— Continued, 579 

Retained Placenta — Acute Inversion of the Uterus — Asphyxia 
Neonatorum. 

CHAPTER XVIII. 

OBSTETRIC OPERATIONS, . . . . . . . . . 591 

Induction of Premature Labor — Induction of Abortion. 



xxii Contents. 



CHAPTER XIX. 

OBSTETRIC OPERATIONS— Continued, 596 

Turning — Conditions Calling for the Operation — Favorable Conditions 
— Cephalic Version — Podalic Version. 

CHAPTER XX. 

OBSTETRIC OPERATIONS— Continued, . ... . .605 

The Forceps — The Short Forceps — The Long Forceps — Salient Fea- 
tures of the Instrument — Axis-traction Forceps — Designations of the 
Blades — Action of the Forceps — Modes of Application — Conditions 
Calling for the Forceps—The Preliminaries — The Application — 
Traction — Forceps in Occipito-posterior Positions — The Forceps in 
Face Presentations — Use of the Forceps on the Breech — The Forceps 
to the After-coming Head. 

CHAPTER XXI. 

MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS, . . 620 
The Vectis — The Blunt Hook — Hypodermic Injections — Cathe- 
terism — Mode of Performance. 

CHAPTER XXII. 

OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS, . 624 

Craniotomy — Frequency — Its Sphere — The Perforator — The Crotchet — 
Craniotomy Forceps — The Cranioclast — The Cephalotribe — Relative 
Value of Different Modes of Reducing Cephalic Dimensions — Embry- 
otomy — Decapitation — Evisceration. 

CHAPTER XXIII. 

OBSTETRIC LAPAROTOMY, LAPARO-ELYTROTOMY AND 

SYMPHYSOTOMY, . . . . . . . . . .634 

Cesarean Section — The Operation — After-care of the Patient — Post- 
mortem Cesarean Section — Post-mortem Delivery through the 
Natural Passages — Porro's Operation — Comparison of Cesarean 
and Porro Operations. — Laparo-elytrotomy — Symphysotomy. 



Contents. xxiii 



PAET IV. 
THE PUERPERAL STATE. 



CHAPTER I. 

PHENOMENA AND MANAGEMENT OF THE PUERPERAL STATE, 650 
Puerperal Mortality — Phenomena Succeeding Delivery — The 
Pulse — Post-partum Blood Changes — Temperature — Uterine Involu- 
tion — After-pains — The Excretions — Changes in the Uterine Mucous 
Membrane — Vaginal Changes — The Lochia — The Lacteal Secretion — 
Management of the Breasts in Non-nursing Puerper^e — Gen- 
eral Attention to the Puerperal Woman — The Physician's 
Visits — Retention of Urine — Regimen — The Bowels — Time for 
Getting Up. 

CHAPTER II. 

THE PUERPERAL DISEASES, 675 

Phlegmasia Alba Dolens — The Simple Form — The Malignant or 
Infectious Form — Prognosis — Treatmen t. 

CHAPTER III. 

THE PUERPERAL DISEASES— Continued, 686 

Sudden Death During Labor and the Puerperal State — Pul- 
monary Thrombosis and Embolism — Syncope — Entrance of Air into 
the Veins — Violent Emotions — Organic Heart Lesions — Defective 
Lacteal Secretion — Depressed Nipples — Excessive Lacteal 
Secretion — Sore Nipples — Mastitis Puerperalis — Etiology and 
Symptomatology — Pathology — Treatment. 

CHAPTER IV. 

PUERPERAL FEVER, . . . . . .' . . . .708 

Definition — History — Etiology — Frequency — Symptoms — Dura- 
tion — Diagnosis — Prognosis — Prophylaxis — Post-mortem Ap- 
pearances — Treatment — Therapeutics — The Curette — Refrigeration 
— Conclusions. 



APPENDIX. 

ANTISEPTIC MIDWIFERY, 72 i 

History— Reduction of Mortality— Prevention of Infection— Before 
Labor — During Labor — Treatment of Puerperal Infection. 



MHBBM^^Bai 



THE 

SCIENCE AND ART OF OBSTETRICS. 



PAET I. 

ANATOMY AND PHYSIOLOGY OF THE FEMALE 
PELVIC ORGANS. 



CHAPTER I. 
ANATOMY OF THE PELVIS. 

An acquaintance with the anatomy of the female pelvis is 
indispensable to an intelligent comprehension of the details of 
the Science and Art of Obstetrics, and ought to be insisted upon 
as apreliminar}^ to the study of this branch of medicine. Anat- 
omy is, in truth, the A B C of medicine and surgery, and 
our progress in the latter will largely depend on our knowledge 
of the former. 

The pelvis constitutes a bony case, or basin, within and 
upon which are all the organs directly concerned in the process 
of reproduction. Not only this, but through the canal by 
it formed, the foetus passes in the act of parturition. 

Component Parts of the Pelvis.— In the adult, it is com- 
posed of four distinct bones, namely, the two ossa innominata, 
the sacrum and the coccyx. The ossa innominata are united 
anteriorly, and, from their peculiar form, constitute the ante- 
rior and lateral walls of the pelvis. Posteriorly these bones 
articulate with the sacrum, which is interposed between their 
extremities. The coccyx is joined to the sacrum inferiorly in 
such a manner as to continue and complete the latter's 
structure. 

The Os Innominatum— This bone is formed by the union 
of three parts, the ilium, ischium and pubis, the perfect fusion 
of which gives to the bone a form unlike that of any other in 
the human frame. Osseous union of the parts is completed 
about the twentieth year. The bone is so irregular in shape, 
(l) 



^■H^^^H 



2 



Anatomy of the Pelvis. 



that a description of it, however carefully given, would utterly 
fail to create in the mind, without the aid of a specimen or 
drawing, a clear conception of its anatomical characters. It is 
truly the nameless bone. It is formed of three parts, distinct 
in the infant and young child, united at the acetabulum, at first 
by cartilaginous, but eventually by osseous, structures. The 
lines of junction form a figure resembling the letter Y, but, after 
complete ossification, the evidences of primary individuality 
become almost wholly obliterated. 

These three portions of the os innominatum have been 
named: 1. The os ilium hip, or haunch bone; 2. The os 

ischium, or sitting bone; 
and 3. The os pubis, pecten 
or share bone. 

Outer Surface.— The chief 
obstetric interest in con- 
nection with the innominate 
bone is directed to its inner 
surface. 

Upon its outer surface are 
attached certain muscles, 
some of which render in- 
direct aid in parturition, 
but are not indispensable 
to its easy performance. 
Powerful abdominal mus- 
cles find attachment to the 
crest of the ilium, which, 
with those springing from the tuber ischii and contributing to 
the structures forming the pelvic floor, exercise considerable 
influence over the parturient act. 

Looking at its outer superficies we observe the broad, flat 
ilium, the bent ischium, and the projecting pubis, while at the 
point where these several parts are united, is the smooth, round 
depression known as the acetabulum, or cotyloid cavity, into 
which is received the head of the femur. We also notice in the 
dried specimen an aperture situated between the pubis and 
ischium, which, in the recent subject, is filled, or covered, with a 
membrane or ligament, which gives to the opening its name, 
the obturator foramen. 

A small aperture only is formed superiorly, which serves to 
transmit the obturator vessels and nerve. 




Fig. 1. — The right Os Innominatum. 
(Outer surface.) 



Components of the Pelvis. 



3 



Inner Surface.— Bringing under view the inner surface, we 
observe that the bone is divided into a superior and an inferior 
part, by a ridge which traverses it transversely. This is termed 
the ilio-pectineal line, taking its name from the iliac and pubic 
portions of the os innominatum. On the lower and posterior 
part of the ilium is a roughened, ear-shaped surface, being the 
portion of bone which articulates with the sacrum, known as 
the auricular surface. These features being given, no further 
study need now be made of the os innominatum as a whole. Its 
several parts, however, are worthy further attention. 

The Os Ilium.— This is the largest of the three, triangular 
in shape, situated superiorly, and, with its fellow of the oppo- 
site side, forming what 
is called the false pel- 
vis. It presents an 
irregular, convex, ex- 
ternal surface, with 
elevations and depres- 
sions which afford at- 
tachments for the 
glutei muscles. Its op- 
posite or internal sur- 
face is smooth and 
concave, forming a 
fossa for the broad, 
flat iliacus inter nus 
muscle. It is united 
to the other parts of 
the innominate bone at its lower anterior margin by what is- 
termed the body or base, which is thicker than other parts. 
The ilium, being broad and flat, forms an ala, or wing. Its 
superior margin, thickened into a lip for the attachment of cer- 
tain muscles, is termed the crest. Upon the prominent anterior 
margin there are two eminences — one above, and the other 
below — known as the anterior superior and anterior inferior 
spinous processes. The body of the bone is separated from 
the wing on the inner surface by a well-defined ridge, which 
forms part of the ilio-pectineal line, and marks the boundary of 
the true pelvis. 

The Os Ischium.— The bone is situated anteriorly and infe- 
riorly to the ilium, and is joined to the latter at the acetabulum. 

Projecting forwards and upwards from the base, which is the 




Fig. 2. 



-The right Os Innominatum. 
(Inner surface.) 



4 Anatomy of the Pelvis. 

thickest and strongest part of the structure, is a thinner por- 
tion, the ascending ramus, which is united to the descending 
ramus of the pubis, and aids in forming the obturator foramen 
and pubic arch. Between the two extremities of the ischium is 
a thick, strong portion, projecting downwards and constituting 
the most inferior part of the pelvis. This, from its form, is 
called the tuberosity of the ischium. Pointing downw T ards, 
backwards and inwards from the body of the bone, is a point of 
considerable obstetric importance, which has been termed "the 
key to the mechanism of labor," i. e., the spine of the ischium. 

The Os Pubis. — This is a light v-shaped bone, situated most 
anteriorly, articulating with the ilium and ischium at the ace- 
tabulum, and with its fellow anteriorly. The body of the bone 
at its acetabular articulation is the thickest part, while from 
this there extends forwards and inwards a thinner part which 
is the horizontal ramus. The articulation of the pubis with its 
fellow of the opposite side is called the symphysis pubis, and 
from this part of the bone there stretches downwards, back- 
wards and outwards a thin plate, the descending ramus, which 
joins the ascending ramus of the ischium. The superior margin 
of the pubis forms a continuation of the ilio-pectineal line. 
Near the symphysis pubis is an elevation, the spine of the pubis, 
to which is attached Poupart's ligament, and close to it the 
pectineus muscle. The pubis by its anterior articulation forms 
that important pelvic feature the pubic arch. 

In figure 1 is shown the outer surface of theosinnominatum. 
(1) is the ilium, (2) the acetabulum, (3) the crest of the ilium, 
(4) the anterior superior spine and (5) the anterior inferior 
spine of the ilium, (16) the horizontal ramus of the pubis, (19) 
the spine of the pubis, (20) the obturator foramen, (15) the 
ascending ramus of the ischium, (14) the tuberosity of the 
ischium. 

Figure 2 shows the inner surface of the os innominatum. (1) 
is the articular surface of the ilium, (2) the ascending ramus of 
the ischium, (3) the spine of the pubis, (4) the anterior supe- 
rior and (5) the anterior inferior spine of the ilium, (6) (7) the 
posterior, superior and inferior spines of the ilium, (8) the sci- 
atic notch, (10) the iliac fossa, (12) the ilio-pectineal line, (13) 
the spine of the ischium and descending ramus of the pubis, 
(20) the obturator foramen. 

The Sacrum, or Basilare— -It is difficult to understand why 
this bone should have received a name indicating a quality 



Components of the Pelvis. 5 

of holiness,— for sacrum means holy,— and that so general 
an idea of sanctity should have been connected with it in 
ancient times, by many different nations. It may be related in 
some way to the belief current among the Jews that "there is a 
small bone in the body which is indestructible, and which at the 
resurrection will gather about it, as to a center, all the other 
parts of the body and rise bodily into everlasting life." 

The sacrum is a triangular bone, forming the base or lower 
termination of the spinal column, and binding together the 
ossa innominata. It is composed originally of five separate 
rudimentary vertebrae, of graduated sizes, which by their junc- 
tion resemble a pyramid, with the apex downwards, its base 
forming a sea,t or plith, on which rests 
the last lumbar vertebra. The seams 
between the several vertebrae thus 
united, are distinct, and the edges of 
the bones form prominences easily felt 
on vaginal examination. 

The sacrum presents six surfaces 
for study, all of which are, in their 
main characters, of some interest to 
the obstetrician. The bone has a 
decided curve longitudinally, and a 
slight one from side to side, with the 
concavity looking inwards. Its supe- 
rior, inferior and lateral surfaces are 
articular. The superior surface, or Fig. 3.— The anterior surface 
base, articulates with the last lumbar of the Sacrum, 

vertebra by means of an inter-articular disk of cartilage, and 
thus forms the lumbosacral, or sacro- vertebral joint. The in- 
tervening cartilaginous disk, from being thicker anteriorly than 
posteriorly, causes the base of the sacrum to project more than 
it otherwise would. This part of the bone, thus rendered promi- 
nent, is known as the promontory of the sacrum. The superior 
portion of either lateral surface articulates with the ilium to 
form the ilio-sacral synchondrosis. The small apex articulates 
with the coccyx below to form the sacro-coccygeal joint . 

Looking at the inner surface of the bone, we discover on 
either side of the bodies of the fused vertebrae four openings, 
formed by the transverse processes. These are the sacral foram- 
ina, and transmit the anterior sacral nerves, which contribute 
to the formation of the great sciatic nerve that passes down 




Hi 



6 Anatomy of the Pelvis. 

the outside of the thigh. The cavity formed by the sacra] 
curves is known as the hollow of the sacrum: an important 
feature for the student to remember in connection with intra- 
pelvic anatomy. The surface of the bone is comparatively 
smooth, thereby favoring an easy passage of he foetus through 
the pelvic canal. 

The outer surface presents an entirely different aspect, being 
rough and tuberculous. In the median line are the spines of the 
vertebrae, while on either side are discovered openings which 
correspond to those on the inner surface, and which serve to 
transmit the posterior sacral nerves. The roughness of the pos- 
terior surface serves a wise purpose, since the tubercles give 
firm attachment to ligaments and muscles of much power and 
importance, especially those which serve to maintain the erect 
posture. The entire bone is penetrated longitudinally by 
the spinal canal, containing the terminal nerves of the spinal 
cord, which, from their bundle shape, are known as the cauda 
equina, or horse's tail. 

The Coccyx, or huckle-bone, is small and composed origi- 
nally of four rudimentary vertebrae, which do not become ossified 
into one piece until middle life. In shape it somewhat resembles 
the sacrum, and is so articulated as seemingly to form a part of 
that bone. It may be regarded as the tail-bone of the species. 
Like the sacrum, it is turned base upwards, and apex down- 
wards. 

Two styloid processes project from the posterior lateral sur- 
faces and rest upon the back part of the apex of the sacrum, 
thus preventing too great repression of the point of the bone 
during descent of the foetus. There are corresponding cornua 
on the opposing part of the sacrum. The curve begun by the 
sacrum is so far extended by the coccyx that the latter bone is 
made to form part of the floor. Its apex represents the pos- 
terior pole of the conjugate diameter of the outlet, which diam- 
eter is considerably amplified during expulsion of the foetus 
by a recession of the apex, through movement at the sacro- 
coccygeal joint. 



Articulations of the Pelvis. 



CHAPTER II. 

THE ARTICULATIONS AND GENERAL CHARACTERS OF THE 

PELVIS. 

Having viewed the separate bones which make up the pelvis, 
we may now consider the articulations which result from their 
connection. We shall notice, (1) the symphysis pubis ; (2) the 
ilio-sacral synchondroses, (3) the sacro-coccygeal articulation; 
in each of which the student of obstetrics will take interest. 

The Symphysis Pubis is the articulation situated directly in 
front, resulting from the approximation of the two pubic 
bones. The articular surface of the bones is small, since the 
bone itself at this place is comparatively thin. The surface is 




Fig. 4. — Section of the Symphysis Pubis. 

invested with fibrocartilage, thickened anteriorly where the 
surface comes in contact with its fellow, and thinned posteriorly 
so as to leave a small space in which is a synovial sac. 

The bones thus articulated form an arch, called the pubic 
arch, the crown of which is directly at the symphysis. It is 
highly important that the student bear in mind the existence, 
situation and form of this arch, inasmuch as under it the foetus 
passes in parturition. A shortening of the span of the pubic 
arch operates to increase the pelvic depth anteriorly, and add 
greatly to the difficulties and dangers of parturition. 

The Ilio-Sacral or Sacro-Iliac Synchondroses.— Atten- 
tion has already been directed to the auricular surfaces of both 
the ilium and sacrum, the junction of which makes the joint 
under consideration. The bones once in position, we have, then, 
two synchondroses (so called), the right and left. The articular 



IHH 



8 



Anatomy of the Pelvis. 



surfaces are, in the recent subject, covered with fibrocartilages, 
and there is found between them, as in the other pelvic articu- 
lations, a synovial membrane, which becomes more distinct 
during the latter part of pregnancy. 

Mechanical Relations of the Sacrum.— If we regard the 
sacrum, as does Dr. Matthews Duncan, as a strong transverse 
beam, curved on its anterior surface, with its extremities in 
contact with the corresponding articular surfaces of the ossa 
innominata, the important medical relations sustained by the 




Fig. 5. — Section through the left Sacro-iliac Articulation. 
(Natural size.) 



ilio-sacral synchondrosis at once becomes apparent. The 
weight of the body is transmitted to the innominate bones, and 
through them to the femurs. Counterpressure is applied, and 
there is thus exerted an important modifying influence on the 
development and shape of the pelvis. 

The Sacro-coccygeal Joint. — This is a ginglymoid joint, 
formed by the articulation of the bones from which its name is 
derived, and by means of it labor derives considerable mechan- 
ical advantage. When the long diameter of the head, in its 
progress through the pelvis, rotates into the conjugate of the 



Articulations of the Pelvis. 9 

pelvic outlet, the latter diameter, by movement backwards of 
the coccyx under pressure, is so amplified as to afford greater 
facility for escape of the foetus. This movement, however, 
is not confined to the joint itself, but is generally shared by the 
points of ossification of which the coccyx is made up. This is 
especially true of the second and third, and the first and sec- 
ond segments. 

The proximal surfaces here, as at the other articulations, 
are covered with cartilage, and betw r een them is found a serous 
membrane. 

Anchylosis of the sacro-coccygeal joint, and premature ossi- 
fication of the separate pieces of the coccyx, may take place, and 
give rise to much delay, difficulty and suffering during descent 
of the head. Such anchyloses have been known to snap under 
pressure, with an audible report. Anchylosis of this joint con- 
stitutes an impediment to labor, and may necessitate forcible 
rupture through instrumental delivery. In all such cases a cer- 
tain amount of attention should be bestowed on the reparative 
process, to prevent reunion of the parts with the coccyx in an 
unnatural position. 

The Ligaments of the Pelvis.— These are by no means 
few in number, when those which are in close relation to the ar- 
ticulations are included. The symphysis pubis receives strength 
from ligaments stretched from one bone to the other on every 
side of the joint. We therefore have superior and inferior, inner 
and outer, ligaments. Of these, the posterior is a layer of fibers 
of little strength ; the superior is connected with a band of fibers 
which arises from the spine of the pubis, and conceals the 
irregularities of the crest of the bone. The anterior is a layer 
of irregular fibers passing from one side to the other, and cross- 
ing obliquely the corresponding fibers from the other side; and 
the inferior, triangular, or sub-pubic ligament is so thick, and 
so shaped by its attachments to the rami of the pubes, as to 
give smoothness and roundness to the sub-pubic angle, and 
thereby to facilitate passage of the foetus through the pelvic 
canal. 

The ligaments which stay the ilio-sacral synchondroses are 
so arranged as to give the articulations great strength. The 
posterior sacro-iliac ligament consists of strong irregular bands 
of fibers, w T hich pass from the overhanging portion of the ilium 
to the contiguous rugged projections on the lateral surface of 
the sacrum. One of these bands, prolonged from the posterior 



^■i 



10 Anatomy of the Pelvis. 

superior iliac spine to the third or fourth vertebra of the 
sacrum, in a direction different from the others, is known under 
the name of the inferior, or oblique, sacro-iliac ligament. 

The anterior sacro-iliac ligament is a simple fibrous lamina, 
extended transversely from the sacrum to the os innominatum. 
It is rather an expansion of the periosteum than a true liga- 
ment. The superior sacro-iliac ligament is a very thick fascicu- 
lus, passing transversely from the base of the sacrum to the 
posterior part of the inner surface of the bone. 

These synchondroses are strengthened also by the sacro- 
sciatic ligaments, — greater and lesser. The greater, or poste- 
rior, arises from the posterior margin of the ilium, including 
the posterior inferior spine and the lateral surfaces of the sacrum 
and coccyx. It is broad and flat, but its fibers con verge as they 
pass downwards and forwards to be inserted into the inner 
surface of the ischial tuberosity. The anterior or small sacro- 
sciatic ligament is triangular in shape, but shorter and thinner 
than the other. The origin of its base is blended with that of 
the greater, but is less extensive, and its apex is attached to the 
spine of the ischium. 

These ligaments transform the sciatic notch into two foram- 
ina, the greater and the lesser sacro-sciatic. Through the 
former of these pass the pyriformis muscles, the great sciatic 
nerves, and the ischiaticand pubic vessels and nerves. Through 
the latter pass the obturator internus muscles, and the internal 
pubic vessels and nerves. 

The functions of these ligaments is tersely put by Leishman 
as follows: "They act, as has already been mentioned, by pre- 
venting the displacement of the apex of the sacrum upwards 
and backw r ards, — an accident w^hich, without their aid, the very 
oblique position of that bone would, in the erect position, be 
likely to engender; and therefore, in this sense, they strengthen 
the sacro-iliac articulation. But in addition to this, they close 
in, in some measure, the large irregular opening which consti- 
tutes the outlet of the pelvis, forming at the same time the 
framework of those soft structures which constitute the floor 
of the pelvis. The floor thus constructed exercises a very im- 
portant influence on the progress of labor, and at the same 
time affords an efficient and elastic support to organs which 
would otherwise be liable to frequent displacement down- 
wards.'' 

The ligaments which strengthen the lum bo-sacral joint are 



Articulations of the Pelvis. 



11 



similar to those which join one vertebra to another. The 
anterior common vertebral ligament passes over the surface of 
the joints ; and we also find the ligamenta sub-flava and inter- 
spinosa, as in the other vertebra?. The articular processes are 
joined together by a fibrous capsule, and there is also a special 
support given by the lumbo-sacral ligament, which stretches 
from the last lumbar vertebra on each side, and is attached to 
the side of the sacrum and the sacro-iliac synchondrosis. Men- 
tion should also be made of the ilio-lumbar ligament, which 
passes from the apex of the last lumbar vertebra to the thickest 
portion of the iliac crest. 




Fig. 



The articulated Pelvis. 



The ligaments of the sacro-coccygeal articulation require but 
brief notice. The anterior consists of a few parallel fibers which 
descend from the anterior part of the sacrum to the correspond- 
ing face of the coccyx. The posterior sacro-coccygeal ligament 
is flat, triangular, broader above than below, and of a dark 
color. Arising from the margin of the inferior orifice of the 
sacral canal, it descends to, and is lost on, the whole posterior 
surface of the coccyx. It aids also in completing the canal 
behind. These ligaments seem to embrace the entire joint in a 
kind of capsule. 

A few words remain to be said regarding the obturator liga- 
ment or membrane. As has been elsewhere stated, this struc- 



12 



Anatomy of the Pelvis. 



ture is stretched over the obturator foramen, almost closing it, a 
small opening only being left for the passage of the obturator 
vessels and nerve. It is spoken of as a ligament, but it is thin, 
and in structure resembles an aponeurosis. 

The Pelvis as a Whole.— Having made a somewhat detailed 
study of the several bones, joints and ligaments which con- 
tribute to form the pelvis, let us now view the structure as a 
whole, and note its remarkable characters. And as we do so, 
first of all we observe that by means of the peculiar form given 
it by the ilio-pectineal line and sacral promontory (which con- 
stitute the superior strait, or pelvic brim), the pelvis is natu- 




Fig. 7.— Showing the Diameters of the Superior Strait. 

rally divided into superior and inferior parts, the former being 
termed the false pelvis, and the latter the true pelvis. In the 
living or recent subject, then, the false pelvis is bounded ante- 
riorly by the abdominal walls, laterally by the broad flat wings 
of the ilia, posteriorly by the lumbar vertebra? and the pos- 
terior portions of the ilia, and inferiorly by the plane of the 
superior strait. The true pelvis is bounded posteriorly by the 
sacrum, laterally by the ischia and bodies of the ilia, ante- 
riorly by the pubes, superiorly by the brim of the pelvis, or 
superior strait, and inferiorly by the outlet, or inferior strait. 
The broad expanded alas of the ilia, the ischial tuberosities, the 
sacral promontory, and the pubic arch, are all peculiarities of 



Anatomy of the Pelvis. 



13 



the structure that should be noticed. Within the true pelvic 
cavity, the hollow of the sacrum, formed by the curve of that 
bone, and the ischial spines, demand special attention. 

We shall shortly enter upon a more minute study of the 
pelvic cavity, a part replete with interest, since it is the home 
of the unimpregnated uterus and appendages, and through it 
passes the foetus on its way to light and liberty. 

Dimensions of the Pelvis.— Before proceeding further, the 
student will do well to familiarize himself with the dimensions 
of the pelvis. In giving these, certain terms will be used which 
require definition. 




Fig. 8. — Showing the Diameters of the Outlet. 



Referring now to figure 7, w r e have a diagram of the superior 
strait, or pelvic brim : a-b represents the antero-posterior, or 
conjugate diameter, the poles being at the symphysis pubis and 
sacral promontory; c-d designates the transverse diameter ; e-f 
shows the left-oblique diameter, the poles resting at the right 
acetabulum or ilio-pectineal eminence and the left sacro-iliac 
synchondrosis ; f-e marks the right-oblique diameter, the poles 
being found at the left ilio-pectineal eminence, or left acetabulum, 
and the right sacro-iliac synchondrosis. 

With regard to exact dimensions, we should recollect that 
they can scarcely be given with any degree of assurance, inas- 
much as actual measurements are found to be so various. It is 
only by taking the average diameters of a large number of pelves 
that w r e can acquire a clear idea of pelvic dimensions. But 



14 Anatomy of the Pelvis. 

what is of vastly greater importance than exact figures for the 
student of obstetrics to remember, are the relative measure- 
ments. 

In the figures which follow, reference is had to the dried 
pelvis, divested of all soft parts save ligaments ; but before sub- 
mitting them a word is required with regard to the oblique and 
conjugate diameters of the pelvic cavity and outlet. In the 
instance of the former, one pole necessarily rests on the sacro- 
sciatic ligaments, and hence is not fixed. This is also true of 
the conjugate of the outlet, one pole of which diameter rests on 
the tip of the coccyx ; and this bone, as has been explained, is 
pressed more or less backwards during descent of the foetal 
head, thereby lengthening the diameter. 

The following will then approximate the actual diameters of 
the true pelvic cavity, and of its superior and inferior straits : 

Conjugfte. Transverse. Oblique. 

Brim, or superior strait .... A% h% 5 

Cavity . 5^ 5 (5^) 

Outlet 5 to 6 4% (4%) 

Other pelvic measurements are also submitted : — 

Circumferential measurement of the brim 17 

Measurement from the sacral promontory to the center of the 

acetabulum, or the ilio-pectineal eminence .... 3)£ 

Between the widest part of iliac crests 10% 

Between the anterior superior iliac spines 103^ 

Between the front of symphysis and sacral spines .... 7 

From the diameters of the true pelvis, as given, it will be ob- 
served that at the brim the conjugate is the shortest, and the 
transverse the longest. In the living subject, however, these 
relative dimensions are changed. The transverse diameter, 
from encroachment of the psose and iliac muscles, becomes 
shorter than the oblique. Then, on account of the presence of 
the rectum on the left side of the sacral promontory, the left 
oblique diameter is slightly diminished. The result of these 
changes is that the right oblique becomes the longest diameter, 
and hence the long diameter of the head is most frequently 
found in it. 

Inclination of the Pelvis. — When the pelvis is placed upon 
a flat surface, so that the ischial tubers and coccygeal tip are 
brought upon the same plane, we do not get an accurate idea of 
the position which this part of the skeleton really occupies in 
the living, erect subject. Without entering into a narrative of 



Planes of the Pelvis. 



15 



the different notions which have from time to time been held, 
it will answer practical purposes to say that the pelvis is so 
placed that, in the erect position, what are termed its horizon- 
tal planes sustain a marked inclination. This is an important 
fact, and should be clearly apprehended. 

Now it has been found, that, while the inclination of the pel- 
vis varies in different persons, and in the same person at differ- 
ent times, the general pitch of the plane of the superior strait is 
at an angle of say 60 degrees, and that of the inferior strait, 



COCCYX \A 



PUSHES BACK 




OBSTETRICAL CONJUGATE 
HORIZON. 



before recession of the coccyx, about 11 degrees with the hori- 
zon. The high practical value of these items of information 
will be clearly discerned as we proceed. 

Planes of the Pelvis.— It is not difficult to demonstrate 
what is meant by pelvic planes. That of the superior strait 
would be well represented by a piece of cardboard fitted into 
the irregular outline of this aperture. When viewed in con- 
jugate section, the plane of the brim would be represented by a 
line drawn from the superior margin ofthepubes to the promon- 
tory of the sacrum. A piece of cardboard fitted into the outlet, 
so that one side of it would rest on the point of the coccyx, the 
opposite side at the crown of the pubic arch, with its lateral 
borders extending between the ischial tubers, w T ould represent 



16 



Anatomy of the Pelvis. 



the plane of the outlet. This plane, in a section like that in 
figure 9, would be represented by a line drawn from the sub- 
pubic margin to the tip of the coccyx. The change produced by 
recession of the coccyx is also well shown in the same figure. 

Planes without number may be created within the pelvic 
cavity by carrying forward the lines representing the planes of 
the superior and inferior straits to the point of intersection, 




Fig. 10. 



Fig. 11. 



and from this, as a center, radiating other lines through the 
pelvis, as shown in figure 10. 

Axis of the Parturient Canal.— The axis of the partu- 
rient canal is its geometrical center. To demonstrate the axis 
of a perfect cylinder would not be difficult, but the parturient 
canal is a cavity of irregular dimensions, with diameters short 
in one part and long in another, and a depth much greater pos- 
teriorly than anteriorly. The axis of the pelvic brim is rep- 
resented by a line drawn through its center perpendicularly to 
its plane, which, if extended, would touch at the umbilicus and 



Planes of the Pelvis. 



17 



the coccyx. The axis of the outlet of the bony pelvis intersects 
this, and extends from the promontory of the sacrum through 
the geometrical center of the plane in question. 

A good deal has been said by obstetrical writers about the 
" curve of Carus," and students should be made to understand 
its practical significance. It is formed in the following manner : 
The compasses are expanded so that when one point is 
placed at the middle of the posterior surface of the symphysis, 
the other will rest midway upon the conjugate diameter. The 
latter point is then made* to describe a curve through the pelvic 
canal, and the line resulting is the curve sought. For practical 
purposes this will answer, yet it cannot be regarded as the 
real pelvic axis, since the posterior wall of the cavity has not a 
uniform curve. It is only by 
creating a large number of arti- 
ficial planes like those represent- 
ed in figure 10, and determining 
the geometrical center of each, 
that we approximate exactness. 
A line drawn through the center 
of such planes, from pelvic inlet 
to outlet, would be found to de- 
scribe an irregular parabola, per- 
fectly demonstrating the true 
axis of the pelvic canal. 

It must not be supposed that 
the plane of the bony outlet 
truthfully represents the plane 
upon which the foetal head passes 
the vulva. The yielding pelvic 
floor is greatly stretched, and if the posterior boundary of the 
plane be established at the posterior vaginal commissure, we 
discover that the plane forms with the horizon an angle of 75 
or 80 degrees. This is fully set forth in figure 11: a-b is the 
newly formed plane of the vulva, r is the anus, and e the line 
representing the axis of the parturient canal. 

The Inclined Planes.— When we look at a section of the 
pelvic canal, like that here shown, we observe that the lateral 
wall is easily divided into two parts, by a line extending from 
the ilio-pectineal eminence to the spine of the ischium b-a. That 
part of the bone in front of the line is inclined inwards, down- 
wards and forwards, while that behind the line is inclined in- 

(2) 




18 



Anatomy of the Pelvis. 



wards, downwards and backwards. These are the anterior and 
posterior inclined planes of the ischium. They sustain very 
important relations to the mechanism of rotation of the foetal 
head in the pelvic cavity, as will be shown in a subsequent 
chapter. 

Male and Female Pelves.— With dried specimens before us, 
it is apparent, even on cursory comparison, that there is a dif- 




Fig. 13— Male Pelvis. 

ference between the male and the female pelvis. In order to 
render the variations explicit in detail, the following contrast 
has been drawn : 



MALE AND FEMALE PELVES COMPARED. 



FEMALE. 

1. All the bones are comparatively 
light in structure, and the points 
for muscular attachments are only 
moderately developed. 

2. The iliac wings are widely 
spread, so that when seen from 
before the broad expanse of the 
iliac fossae comes plainly into view. 

3. The ischial tuberosities are 
widely separated, so as to give a 
transverse diameter at the outlet of 
4% inches. 



1. All the bones are comparatively 
heavy in structure, and the points 
for muscular attachments are well 
developed. 

2. The iliac wings are not widely 
spread. 



3. The ischial tuberosities are com- 
paratively near, giving a transverse 
diameter at the outlet of say Z% or 
4 inches. 



Male and Female Pelvis. 



19 



4. The sub-pubic angle is obtuse 
(90° to 100°), and span of the arch 
broad. 

5. The pelvic cavity is wide and 
shallow, and the sectional area of 
the brim and outlet about equal. 



6. The sacrum is broad, and its 
promontory moderately prominent. 



4. The sub-pubic angle is acute 
(70° to 75°), and the span of the 
arch narrow. 

5. The pelvic cavity is narrow 
and deep, and the sectional area of 
the outlet considerably below that 
of the brim, giving to the pelvis a 
funnel shape. 

6. The sacrum is comparatively 
narrow, and the promontory very 
prominent. 




Fig. 14. — Female Pelvis. 



7. The obturator foramina are 
triangular in form. 

8. The spines of the ischia have a 
moderate projection into the pelvic 
cavity. 



7. The obturator foramina are 
more oval in shape. 

8. The ischial spines are remark- 
ably prominent. 



These differences between the male and the female pelvis are 
probably the result of the growth and development of the 
female internal generative organs, situated within the true 
pelvis. Schroeder, in proof of this, calls attention to the fact 
that in women with congenital defects of these organs, and in 
women who have had both ovaries removed in early life, the 
general form of the pelvis is masculine. 



20 Anatomy of the Pelvis. 

CHAPTER III. 

THE FEMALE GENERATIVE ORGANS. 

The female generative organs have been divided according 
to situation and function into external and internal organs. 
The external organs are those which are in view externally, and 
together constitute the pudenda. They are concerned mainly 
in the copulative act, but through them emerges the foetus in 
parturition. They consist of the mons veneris, the vulva, the 
vagina and the perineum. The internal generative organs are 
concerned mainly in producing the ovum, developing and ulti- 
mately expelling it. They consist of the ovaries, the uterus, and 
the Fallopian tubes. 

The Mons Veneris.— This is a cushion-like eminence situ- 
ated directly upon the symphysis pubis and the horizontal pubic 
rami. It is composed mainly of adipose and fibrous tissue, 
and serves as a protection to the parts during sexual inter- 
course. At puberty it develops a growth of hair, the area thus 
covered forming a pyramid, the apex of which is at the vulva. 
Numerous sweat and sebaceous glands are found opening on 
its in tegumental covering. 

The Vulva.— The vulva is made up of a variety of parts. 
The labia majora are two rounded folds of connective tissue 
containing a variable amount of fat, elastic tissue, and smooth 
muscular fibers. They originate anteriorly, at the posterior 
margin of the mons veneris, and, lying side to side, extend pos- 
teriorly, uniting at the anterior margin of the perineum to form 
the posterior commissure of the vulva. The margins which lie 
in contact, and the entire inner surfaces, are covered with mu- 
cous membrane, while the external surfaces are provided with 
ordinary integument. They are broad and flat in front, i. e., at 
the anterior commissure, but thin and narrow posteriorly. The 
integument for a certain distance from the mons veneris is thin- 
ly covered with hair, and is provided with a considerable num- 
ber of sweat and sebaceous glands. In the mature virgin these 
external lips conceal the other vulvar structures, but in women 
who have borne children they are not so close, and from 
between them peer the labia minora. In young girls and old 
women the labia minora are also prominent. 

The Clitoris.— Separating the labia majora, we find just 



Female Geneeative Organs. 



21 



behind the anterior vulvar commissure, a small elongated body, 
called the clitoris. On careful examination, it is found to re- 
semble the penis in form and structure, and, like the male organ, 
is the seat of the aphrodisiac sense. It differs from the penis in 
having neither corpus spongiosum nor urethra. It is divided 
into the crura, the corpus and the glans. The crura are long, 
spindle-shaped processes, attached to the borders of the as- 
cending rami of the ischii and the descending rami of the pubes. 

The corpus is formed by the 
junction of the crura in the me- 
dian line, in front of the sym- 
physis. The glans is the round- 
ed, imperforate extremity. The 
mucous membrane covering the 
glans is of pale-red color, and 
contains numerous papillae, part 
of which are provided with ves- 
sels, and part nerve endings, sim- 
ilar to those found in the nipple. 

It is supported by a suspen- 
sory ligament which finds attach- 
ment to the anterior and inferior 
margin of the symphysis, while 
the nymphse encircle it in such a 
manner as to provide a prepuce 
and render its likeness to the 
Airile organ more exact. With 
such environment and anchor- 
age, it cannot, when turgid and 
erect become very prominent, 
nor conspicuously display its 
true proportions. The entire or- 
gan measures about three- 
fourths of an inch in length. Its 
blood supply is received from the internal pudic artery through 
the dorsal and cavernous branches ; its veins end in the vesico- 
urethral plexus; and it is provided with nerve communication 
through the internal pudic. 

The Labia Minora.— The labia minora, or nymphse, are two 
folds of mucous membrane, which arise on either side from the 
center of the internal surface of the labia majora. They extend 
anteriorly, forming folds of considerable breadth, and finally 




Fig. 15. — Lateral view of the 
Erectile Structures of the Female 
External Generative Organs. 
(The skin and mucous membrane 
have been removed, and the 
blood-vessels injected.) a, bulbus 
vestibuli. v, plexus of veins called 
the pars intermedia, e, glans 
clitoridis. /, corpus clitoridis. h, 
dorsal vein. /, right crus clitori- 
dis. m, vestibulum. n, right 
gland of Bartholin or Duverney. 



22 



Anatomy of the Pelvis. 



unite at the clitoris. As they approach this organ they bifurcate^ 
the posterior branches being attached to the clitoris, and the an- 
terior uniting to form a sort of prepuce for the organ. In some 
women, even in middle life, the labia minora become so elon- 
gated as to destroy the symmetry of the vulvar structures. 
This is especially true of certain negro races. As elsewhere 

stated, in adult virgins they 
are covered by the external 
labia, but in women who have 
borne children, in the aged and 
in young girls, they show them- 
selves in therima pudendorum. 
In young girls and virgins, the 
Ijj mucous membrane covering 
| their surfaces is of a light pink 
| shade, but in others it is 
Wmk brown, dry, and like skin in ap- 
pearance. The mucous mem- 
brane is provided with tessel- 
lated epithelium, and a large 
number of vascular papilla. 
On their inner surfaces are 
numerous sebaceous glands, 
secreting an odorous cheesy 
matter, which serves for lubri- 
cation and prevents adhesion 
of the folds. 
»'• « "Among some of the Orien- 

§| tals," says Parvin, "the nym- 
H phse are quite large, hindering 
the entrance of the penis, and 
Fig. 16.-Vulva of the Virgin 1, their partial excision was the 
greater lip of right side. 2, four- . . . 

chette. 3, small lip. 4, clitoris, circumcision of females. Cu- 
5, urethral orifice. 6, vestibule. 7, vier states that m the sixteenth 
orifice of the vagina. 8, hymen. 9, century missionaries in Abys- 
orifice of the vulvo-vaginal gland. s i n j a persuaded their converts 
10, anterior commissure of greater tQ abandon the custom, but 
lips. 11, anal orifice. . , , , , „ _ 

as girls could no longer find 

husbands, the pope authorized a return to it." 

The Vestibule.— The vestibule is a smooth, mucous surface, 
triangular in form, with its apex to the clitoris, lying between 
that organ and the anterior margin of the vaginal orifice. It 




Female Generative Organs. 



23 



is bounded on either side by the folds of the nyinphae, and pos- 
teriorly by the vaginal orifice. The mucous membrane of the 
vestibule is smooth, and, unlike the mucous membranes of other 
vulvar parts, is destitute of sebaceous glands. There are a few 
muciparous glands opening on its surface. At the center of the 
base of the triangle formed by the vestibule is situated an open- 
ing, the location of which should be familiar to the physician, 
namely, the meatus urmarius, or meatus urethral. From this 
external opening the urethra passes upwards and backwards 
under the pubic arch, in the tissues which form the anterior 
vaginal wall, a distance of about one and one-half inches, 
to the bladder. It is composed of muscular and erectile tissue, 





Fig. 18. 
Figures showing different forms of Hymen. 

and is remarkably dilatable. With the finger in the vagina, it 
can plainly be felt in the situation described. 

Vaginal Orifice. — The opening of the vagina is directly be- 
hind the vestibule. Its lateral boundaries are the labia minora 
for a short distance, and the labia majora in the main. Its 
posterior boundary is the fourchette, and its anterior the vesti- 
bule. In an undilated state it is a mere fissure, varying consid- 
erably in size. 

The Hymen is a structure of variable thickness and strength, 
situated just within the vagina, and was formerly regarded as 
a seal of virginity. When intact, and of ordinal form, it 
serves as a complete bar to introception of the male organ, 
but it is frequently ruptured in infancy or childhood, through 



24 Anatomy of the Pelvis. 

accidental or other causes. When incomplete, or anomalous 
in structure, sexual congress may be held, and impregnation 
follow, without its destruction. There is a specimen of the fe- 
male genitalia on exhibition in Meckle's museum, at Halle, from 
a woman who gave birth to a seven-months child, which shows 
a perfect hymen. There are also well authenticated cases on 
record of pregnancy existing in women with this part still not 
only of usual proportions, but with only small perforations. 

It is generally crescentic in form, with the free border turned 
toward the anterior vaginal wall. In the main its structure is 
such (being chiefly a fold of mucous membrane with some cel- 
lular tissue and a few muscular fibers), that it tears easily 
under pressure. In other cases it is firm and unyielding, requir- 
ing incision to displace it. 

Anomalies in form are not uncommon. Instead of present- 
ing a free border anteriorly, it may be provided with a single cen- 
tral opening, or there may be a number of small openings. A 
fimbriated hymen is occasionally observed, which might easily 
be mistaken for one freshly ruptured. Instances of imper- 
forate hymen are also met. 

CarunculsB My rtiforrnes— -These are small fleshy tubercles, 
from one to five in number, situated about the vaginal orifice, 
commonly regarded as remains of the ruptured hymen. Schroe- 
der does not concur fully in this opinion. "In primarse," he 
says, "portions of the torn hymen are suffused with blood (dur- 
ing labor), and destroyed by gangrene, so that in the vulva 
some warty, or tongue-like, projections remain." 

The Fossa Naviculars .— In women who have never borne a 
child there still remains a fold of mucous membrane at the pos- 
terior margin of the vaginal orifice, which has been termed the 
fourchette, or framum. Situated between this and the posterior 
vulvar commissure is a little fossa called the fossa navicularis. 
In nearly all first labors the fourchette is torn. 

The Secretory Apparatus.— Sebaceous glands are most 
abundant in the tissues of the nymphse, where they furnish a 
fatty, yellowish-white material, possessing a peculiar odor. 
This, when allowed to accumulate beneath the prepuce of the 
clitoris, constitutes the smegma pra?putii, so common in women 
who neglect the niceties of the toilet. They are also present, as 
stated, though in fewer numbers, on the mons veneris, and 
labia majora. Mucous glands, five to seven in number, are 
found irregularly distributed about the meatus urinarius. 



Female Generative Organs. 



25 



They are of the compound racemose variety, about the size of 
a poppy-seed, and possess short, wide ducts with large orifices. 
Thev are of aid to the beginner in locating the meatus urina- 
rius for catheterism. These lacunae may be sufficiently dilated 
to admit the point of a small-sized catheter, thus constituting 
a deception and snare. 

The VulvQ-Ysbginal Glands were first discovered by Bartholin, 
and have been called "the glands of Bartholin." The name of 
Duverneyhas also been attached to them. They are two in num- 
ber, of the size of a small bean, and somewhat resembling it in 
shape, of a reddish-yellow color. They are situated near the pos- 




Fig. 19. — Vascular supply of Vulva. (After Kobelt.) A, pubis. B B, 
ischium. C, clitoris. D, gland of the clitoris. E, bulb. F, constrictor 
muscle of the vulva. G-, left pillar of the clitoris. H, dorsal vein of the 
clitoris. M, labia minora. 

terior part of the vaginal orifice, behind the posterior extremities 
of the bulbi vestibuli, which they partly overlap. These con- 
glomerate glands are the analogues of Cowper's glands in the 
male. On section, they are found to be of a yellowish-w T hite 
color, and made up of a number of lobules separated from each 
other by prolongations of the external envelope. The several 
ducts of the separate lobules unite in a common canal, about 
half an inch in length, which opens in front of the attached 
edge of the hymen in virgins, and at the base of one of the ca- 
runculse myrtiformes in married women. They secrete a yel- 



26 Anatomy of the Pelvis. 

lowish viscid fluid, which is freely poured out during coitus and 
labor, the office of which is to prevent irritation by rendering 
the mucous surfaces moist and slippery. The glands are larger 
in young girls than in women of middle life, while in old age 
they in some cases altogether disappear. 

The Bulbi Vestibull— The bulbs of the vestibule are two 
curved masses of reticulated veins, somewhat resembling a 
filled leach, about an inch in length, situated between the 
vestibule and pubic arch on either side. They are covered in- 
ternally by the mucous membrane, and embraced on the out- 
side by the libers of the constrictor vaginae muscle. Kobelt 
claims that they correspond to the two separate halves of the 
male bulbus urethra?. The anterior ends, which are rather small, 
are connected by means of the pars intermedia with the glans 
clitoridis. The blood, during sexual excitement, is pressed 
through this communicating channel by reflex action of the 
musculus constrictor cunni, from the turgid bulbs, thereby 
flooding the erectile tissue and hardening the clitoris. These 
vessels are supplied with blood from the internal pubic arteries. 

The Vagina. — This important part of the female genera- 
tive apparatus is by some classed with the internal genitals, 
but it is here considered as an external organ. It is a cylin- 
drical membranous tube, extending from the vulva to the 
uterus, and hence is sometimes called the vulvo-uterine canal. 
It is situated in the pelvic cavity, with the bladder anteriorly, 
and the rectum posteriorly, and, when put upon the stretch, 
extends nearly to the superior strait, following pretty closely 
the general curve of the pelvic axis. Its walls, while strong, 
are soft and yielding, and lie in contact, being, flattened from 
before backwards. There has been considerable discussion over 
the length of this organ, and it is quite certain that the meas- 
urements given by some are excessive. When not drawn 
forcibly out to its greatest length, it can be fully explored with 
a finger measuring three or three and a half inches ; but, when 
at its maximum, the length is probably four and a half inches 
— possibly five. Measurement varies greatly in different women. 
It is sometimes very short, the whole length being only one 
and a half or two inches. It is united to the bas-fond of 
the bladder by condensed areolar tissue, while the urethra is 
situated in its anterior walls. It is connected with the rectum 
in its superior part, by the double fold of peritoneum which 
forms Douglas's pouch, and in its inferior part by areolar tis- 



Female Generative Organs. 



27 







sue. Its lateral borders are attached above to the broad 
ligaments, and below to the pelvic areolar tissue and some 
venous plexuses. The superior extremity, or fornix, encircles 
the cervix uteri below its junction with the corpus uteri, thus 
giving to the cervix a supra-vaginal portion, and an intra- 
vaginal portion. The superior boundaries of the vagina in 
thus folding upon themselves to embrace the neck, form a cir- 
cular groove or cul-de-sac, described 
as the anterior and posterior vagi- 
nal cul-de-sacs. The posterior is 
deeper than the anterior. 

Erroneous ideas are sometimes 
derived from the vagina being de- 
scribed as a tube with an external 
opening. It is a tube or canal, but 
one whose anterior and posterior 
walls are in contact. Its caliber 
varies in different parts, being least 
at the outlet. 

The vagina is composed of an ex- 
ternal, a middle and an inner coat. 
The external consists of cellulo- 
fibrous tissue, which connects it 
anteriorly with the bladder and 
urethra, laterally with the levator 
ani, and posteriorly with the rectum 
and peritoneum. The walls are of 
variable thickness. In the upper part 
of the canal the internal surface is 
smooth, and the thickness of the 
Avails is only half a line to a line, 
while in the lower part it is much 
greater. The external cellulo-flbrous 
tissue coat is very elastic, and af- 
fords a fine bed for the vaginal 
blood-vessels. The middle coat is 
muscular, the fibers being of the 
involuntary variety. They run in both longitudinal and trans- 
verse directions, and are so interlaced that a dissection into 
separate layers is impossible. The connective tissue and mus- 
cular layers increase in thickness as they approach the vaginal 
orifice, the latter constituting two-thirds the thickness of the 




Fig. 20.— The Vagina (af- 
ter removal of posterior 
wall). Ou, meatus urinarius. 
Oue, external os uteri. B, 
section of wall at the fornix 
vaginae. CHenle.) 



28 



Anatomy of the Pelvis. 



vagina. Luschka has described a circular bundle of volun- 
tary fibers, the sphincter vaginas surrounding the lower ex- 
tremity of the vagina and urethra. The action of this muscle 
not only narrows the vaginal orifice, but likewise serves to 
close the urethra by compressing it against the urethro-vaginal 
septum. The sphincter vaginae and the sphincter ani form a 




Fig. 21. — Section of Female Pelvis. 1, rectum. 2, uterus. 3, cul-de-sac of 
Douglas. 4, vesico-uterine space. 5, bladder. 6, clitoris. 7, urethra. 
8, symphysis. 9, sphincter ani. 10, vagina. CKohlrausch modified by 
Spiegelberg.) 

figure of eight. The middle coat of the vagina is dense and 
fibrous, like the proper tissue of the uterus, and is continuous 
with it at the os and cervix uteri. Cruveilhier and other anat- 
omists, have compared it to the dartos. The mucous lining of 



Female Generative Organs. 29 

the vagina, upon the lower portion of the anterior and poste- 
rior walls, in the median line, has two thickened ridges, termed 
the columns rugarum, or vaginal columns. The anterior is 
more prominent than the posterior, and is sometimes divided 
into two portions by a longitudinal furrow. From these two 
columns project folds of mucous membrane at nearly right 
angles, which are heavier and more numerous in the lowermost 
part of the vaginal canal. The rugae, or crista?, as some prefer 
to call them, are most distinct in virgins, less so in women who 
are accustomed to sexual intercourse, and are nearly absent in 
women who have borne children, and in those who have passed 
the child-bearing period. The purpose of these mucous folds is 
double— (1) to afford increased sensational area, and (2) more 
particularly to provide against rupture of the vaginal mucous 
membrane during the immoderate distension which takes 
place in labor. According to Henle, the muscular fibers of the 
vaginal columns possess trabecular arrangement and inclose 
offshoots from the vaginal plexus. Though thus constructed, 
the columns are not properly erectile. When turgid with blood, 
they close the vagina, but the resistance they offer is not for- 
midable, since, like a sponge, they are easily compressed. 

Microscopical examination discloses a large number of vas- 
cular papillae studding the mucous membrane of the vagina, 
which under certain conditions, as those of pregnancy, become 
greatly enlarged, so that to the examining finger they seem 
hard and rough. Writers have frequently described the vagina 
as containing a great number of muciparous glands to which 
is attributed the secretion of the mucus which lubricates this 
tube. It has now become a conviction (unsettled, however, by 
some doubt) that there are no secreting glands. Dr. Tyler 
Smith, who was one of the first to deny their existence, says : 
"The mucus of the vagina is, I believe, produced by the 
epithelium, and consists of plasma and epithelial particles." 
This thin layer of mucus which covers the vagina even in 
periods of repose, is, as was pointed out by M. Donne and Dr. 
Whitehead, distinctly acid. Under sexual excitement, men- 
struation, and during parturition, the amount of secretion is 
greatly increased. 

The lining coat of the vagina resembles ordinary skin almost 
as much as mucous membrane, and in cases of procidentia, 
under external exposure, it becomes converted into dermoid 
tissue. The mucous membrane is reflected over the vaginal 



30 Anatomy of the Pelvis. 

portion of the cervix and os uteri, whereon is everywhere found 
squamous epithelium. 

The vagina is abundantly supplied with vessels and nerves. 
The blood is derived chiefly from the anterior branches of the 
internal iliac through the vaginal arteries, but in part from the 
inferior vesical and internal pudic arteries. 

The arteries form an intricate network around the tube, and 
eventually end in a sub-mucous capillary plexus, from which 
twigs pass to supply the papillae. These in turn again give 
origin to the venous radicals, which, uniting into meshes, freely 
communicate with each other and form a well marked venous 
plexus. The lymphatics conduct to the lateral glands within, 
and the inguinal glands without. 

The nerves are derived from the hypogastric plexus. 

The Perineum.— The peri- 
neum is one of the most impor- 
tant structures in connection 
with the female generative ap- 
paratus, and hence merits most 
careful study. It is situated 
between the posterior vaginal 
commissure and the anus be- 
low, and the vagina and rectum 
above. It presents three sur- 
Fig. 22.— l, vagina. 2, rectum. 3, faces for study, namely, the va- 
triangular notch or space into .j extending upward s from 
which penetrates the perineum. f. . / 

the posterior vulvar commis- 
sure for a distance upon the recto-vaginal septum, the rectal 
surfaces extending from the margin of the anus upwards upon 
the recto-vaginal septum, while the third is that which stretches 
externally between the posterior vaginal commissure and the 
anus. The last constitutes its base, and measures from an 
inch to an inch and a half in length. The perineum is a body 
of considerable thickness, but during expulsion of the foetal 
head it becomes greatly thinned and elongated, so that the 
dimensions of its base, as above described, are greatly in- 
creased. 

The structure of this body is chiefly skin, cellular tissue, 
muscular fibers, and mucous membranes. The peculiar ar- 
rangement of the perineal muscles deserves notice, they being 
inserted by at least one extremity into tendinous structures 
and fasciae. This is true of the sphincter ani, levator ani, 




Female Generative Organs. 



31 



coccygei, transversi perinaei, erectores clitoridis, and sphincter 
vaginae. 

The fibers which are associated to form these several mus- 
cles are comparatively indistinct and are mixed up with a good 
deal of elastic dartoid tissue. Such peculiar construction of the 
perineum is what gives to it the quality of contractility and 
distensibility, so notably manifested during parturition. 



CUTQK©. 




URETHRA. 



CONSTRICTOR 

CUNNl M. 



TRAK5VEBSQ5 PERINAEI. 



Fig. 23. — Muscles of the Perineum. 



The most important muscle which enters into the structure 
of the perineum is the levator ani. This muscle has a double 
structure, is attached anteriorly to the inner surface of the 
bodies and horizontal rami of the pubes, and its lateral halves 
to the tendinous arches of the pelvic fascia?, which stretch from 
the inner borders of the pubes to the ischial spines. From this 
broad origin the muscle extends downw T ards and inwards to the 
sides of the bladder and rectum, and is inserted posteriorly into 
a tendinous raphe, which extends from the top of the coccyx to 



32 



Anatomy of the Pelvis. 











03 


c3 








£ 




?H 


J- 








o3 




_C 


O 






.2 


be 




'o? 


CI 






'E 


^H 




£ 


a 


co 


^ 


>. 


T3 


d 






*e 




o 


c 


_C 


o3 


.2 


o 


<c 


s~ 


s 


5: 


£ 


IS 


-M 


.5P 




o 


03 
> 


e3 


03 


'o 


"5 
pq 


Oft 


h- T 


M ^ £ 


""^ 














ri 


GO 






en 






CD 


•^ 






03 






£ 


03 






-fi 






C 


"E 










U3 


'5d 

o3 


0) 

CO 


CO 


.2 

c 


J 

"E 


CO 

.2 


to 


+3 


O- T3 




,o 


"E 




o 


o 


fl 

3 


'e8 


s 


03 
> 




p. 


o 




^ 


!d 







<f pq o~ q" fxf fsT 





Female Generative Organs. 33 

the rectum. The fibers extending to the rectum become blended 
with those of the external sphincter, while those in relation with 
the vagina are situated beneath the bulbs of the vestibule, and 
the constrictor cunni. The ischio-coccygeus, a small muscle, is 
by some included in a description of the levator ani. It requires 
no detailed notice. 

The levator ani and coccygei muscles are of nearly membra- 
nous thinness, and derive their chief strength, from the strong 
tissues of the internal pelvic fascia, with which they are brought 
into close union. 

The other muscles which contribute to form the pelvic floor 
are of less obstetric importance. They are chiefly the ischio- 
cavernosi, the constrictor vaginse, and the transversi perinsei. 
The ischio-cavernosi muscles form a sheath about the crura of 
the clitoris The constrictor vaginae is made up of two small 
lateral muscles which lie upon the outer side of the vestibular 
bulbs, and surround the vulvar orifice. The transversi perineei 
muscles are small, triangular and thin, extending from the inner 
sides of the ischia, underneath the constrictor muscle to the 
sides of the vagina and rectum. 

It remains to be said of the perineal body that it occupies, 
as stated, the space between the vagina and rectum, and in a 
sagittal section presents a triangular shape as shown in figure 
22. It extends up the recto-vaginal septum nearly half the 
length of the vagina. 

The functions of the perineum are chiefly two: (1) to close 

the lower outlet posteriorly, so as to prevent prolapse of the 

pelvic viscera ; (2) to admit of distension of the vulvar opening, 

when necessary, in such a manner as to produce only temporary 

dilatation. 
(3) 



34 



Anatomy of the Pelvis. 



CHAPTER IV. 

THE FEMALE INTERNAL GENERATIVE ORGANS. 

The Uterus. — About this wonderful organ more obstetric 
interest centers than about any other in the female economy. 
It is pear-shaped, flattened somewhat antero-posteriorly, and 
bent slightly on its longitudinal axis, its concavity looking 
forwards. 

In the virgin the organ differs in shape and size from that in 
the woman w T ho has borne children. The nulliparous uterus 




Fig. 25. — Normal position of the Uterus, with empty Bladder. 

varies in length from two to two and a half inches. Its aver- 
age breadth at the widest point is about one and a half inches, 
while its thickness is about three quarters of an inch. 
Richet gives the following dimensions : 

Vertical diameter Transverse intra- 

of cavity. uterine diameter. 

Inches. Inches. 

Virgins 1.7 .5 

Nulliparae ..... 2.0 1.0 

Multipara* 2.3 1.2 

Its average weight is about 630 grains. 
Its upper border is moderately convex, and its lateral bor- 
ders are convex above and concave below. At the points of 



Internal Generative Organs. 



35 



junction of the lateral and superior borders, being the angles or 
cornua, the Fallopian tubes join the organ. The lower portion 
of the organ is spindle-shaped, and has a width of say three- 
quarters of an inch. 

By reason of its peculiar form the uterus is naturally divided 
into two portions of nearly equal length. The lower portion is 
called the cervix, or neck. The upper portion is subdivided, and 
that part lying below the Fallopian tubes is known as the 
corpus, or body, while that situated above the Fallopian tubes 
is distinguished as the fundus. 

The lower part of the cervix is embraced by the upper 
extremity of the vagina, and this intravaginal end of the cer- 
vix is known as the vaginal portion. 
The remainder of the cervix, which 
lies above or without the vagina, is 
distinguished as the supravaginal 
portion. At the lowermost extremity 
of the cervix there is a slightly trans- 
verse aperture, called the external os, 
or os tincse. In nulliparae it is very 
small, measuring not more than two 
lines in width, and sometimes scarcely 
admitting the point of a small uterine 
sound. This uterine mouth is pro- 
vided with two thick rounded lips, 
the anterior being a little the longer. 

In the adult female the uterus is 
situated in the true pelvis, between 
the bladder in front and the rectum Fig. 26.— Anterior view of 
behind. What we mean to say is, that Virgin Uterus (Sappey). l, 
in the non-pregnant condition it is bod y- 2 2, angles. 3, cervix. 
-u n -^r,- j-u i • -j. j-t- 4, site of os internum. 5, 

wholly within the pelvic cavity, the . , L . . . 

J . r J ' vaginal portion of cervix. 6, 

fundus being below the plane of the external os. 7 7, vagina, 
superior strait. 

The mechanism by which the organ is held in position 
should be thoroughly understood. Lying, as it does, approxi- 
mately in the axis of the pelvic canal, it is to a certain extent 
supported by the vaginal walls and columns, while the latter 
derive much of their supporting power from the perineal body. 

The Uterine Ligaments, from their peculiar arrangement, 
give to the organ considerable freedom of movement, yet serve 
to prevent serious deviations of position or situation. Most of 




36 Anatomy of the Pelvis. 

these are formed by folds of that great serous membrane which 
wraps the pelvic viscera, namely, the peritoneum. This mem- 
brane, after covering part of the posterior surface of the blad- 
der, is reflected upon the anterior face of the uterus, overlying 
the greater part of its superficies. It then passes over the 
fundus uteri, and down the posterior surface, dipping to a con- 
siderable depth, and forming, posteriorly to the upper part of 
the vagina, a serous pouch, bounded laterally by folds of the 
peritoneum. This pouch is the cul-de-sac of Douglas, and the 
folds of peritoneum which form its lateral boundaries are the 
retro-uterine, or utero-sacral ligaments. Anteriorly to the 
uterus— that is, between the uterus and bladder— is a shallow 
pouch with similar ligamentous boundaries formed by the 
peritoneum, the latter being known as the vesico-uterine liga- 
ments. The peritoneum being a broad sheet, or apron, forms 
by its duplicatures, as it passes over the pelvic organs in the 
manner described, broad folds upon both sides of the uterus, 
stretching from this organ to the pelvic wall, known as the 
ligaments lata, or broad ligaments. These divide the pelvis 
into two cavities — the anterior of which lodges the bladder, and 
the posterior the rectum. The superior margin of the broad 
ligament is free, and extends from the angle of the uterus to 
the pelvic wall. The two serous folds which constitute the 
broad ligament are separated by a loose, and very extensible, 
lamellated cellular tissue, continuous with the proper surfaces 
of the pelvis. 

The broad ligaments disappear during gestation, their two 
laminae assisting to cover the anterior and posterior surfaces of 
the enlarged uterus. 

The round ligaments, or supra-pubic cords, are structures 
which differ entirely from those just described, being evidently 
continuous with, and similar in character to, the uterine tissues. 
They arise from the upper border of the uterus, and extend trans- 
versely, and then obliquely, downwards, until they pass through 
the inguinal rings, and blend with the cell ular tissue of the mons 
veneris and labia. In passing through the inguinal rings each 
is invested with a peritoneal sheath called the canal of Nuck. 
Their upper portion is made up solely of the unstriped variety 
of muscular tissue; but, as they descend, they receive striped 
fibers from the transversalis muscles, and the columns of the 
inguinal rings. They also contain elastic and connective tissue, 
and arterial, venous and nervous branches, the first being de- 



Internal Generative Organs. 



37 



rived from the iliac or cremasteric arteries, and the last from 
the genito-crural nerve. 

The uterus thus held by its ligaments is in a freely mobile 
state, such being nature's wise provision to protect the organ 
from injury which it might otherwise receive through violent 
physical exertion, falls, jars, and other disturbing occurrences. 
As previously stated, its longitudinal axis corresponds pretty 
closely with the axis of the pelvic canal, but the fundus of the 
organ in most cases is slightly inclined to the right. 

The Uterine Cavity. — Lateral section of the organ dis- 
closes a cavity in form somewhat like the uterus viewed as 
a whole. Its width c 

at the superior angles, B 

where minute orifices 
mark the openings of 
the Fallopian tubes, is 
greatest, Avhile the nar- 
rowest point is at the 
junction of the body 
and cervix, at which 
place is the uterine 
isthmus. The cavity 
is here a very narrow 
passage, distinguished 
as the internal os. Be- 
tween this point and 
the os tincse there is a 
wider channel, known 
as the cervical canal. 
An antero - posterior 
section reveals but a 
small cavity, with the 
anterior and posterior 
walls lyiug in contact. 
. Structure of the 
Uterus.— Three prin- 
cipal tissues enter into 
the composition of the uterus, namely, peritoneal, muscular, 
and mucous. The manner in which the peritoneum invests 
the organ has been described with sufficient minuteness for 
practical purposes. A good part of the entire area of this organ 
is covered by it. The investment at the sides is less extensive 




Figs. 27 and 28. — B, Median section of Vir- 
gin Uterus. C, transverse section (Sappey). 
B 1 1, profile of the anterior surface. 2, 
vesico-uterine cul-de-sac. 3 3, profile of pos- 
terior surface. 4, body. 5, neck. 6, isthmus. 
7, cavity of the body. 8, cavity of the cervix. 
9, os internum. 10, ant. lip of os externum. 
11, posterior lip. 12 12, vagina. C 1, cavity 
of the body. 2, lateral wall. 3, superior wall. 
4 4, cornua. 5 os internum. 6, cavity of the 
cervix. 7, arbor vitse. 8, os externum. 9 9, 
vagina. 



38 



AiNATOMY OF THE PELVIS. 



than elsewhere, since the peritoneal folds separate a short dis- 
tance below the Fallopian tubes, and there the nerves and ves- 
sels which supply the organ gain entrance. The peritoneum, as 
it covers the upper portion of the uterus, becomes firmly adher- 
ent to it, while below it is more loosely connected. 

The Muscular Structures— The proper tissue of the uterus 
is of a grayish color, and is very dense in structure, creaking 
like cartilage under the scalpel. The cervix is generally less 
firm than the body, a condition resulting, as Mr. Cruveilhier 
believes, from the body and fundus being the more frequent 
seat of sanguinous fluxions. Under physiological as well as 
pathological conditions, the tissue presents a more marked 
redness, and is more supple. 

The uterine tissue is clearly fibrous in character, but the 
nature of the fibers has been a subject of spirited debate. The 
microscope appears to have ended the dispute by showing them 

to be clearly muscular. This is 
J further shown by the develop- 
'i ment that takes place during 
pregnancy, the uterine muscular 
fiber becoming large and power- 
ful. It is certain, then, that the 
proper uterine tissue is chiefly 
muscular, but the fibers in the 
non- pregnant organ are con- 
densed or atrophied, so that 
their true character is in a meas- 
ure concealed. In the latter condition of the organ, the direc- 
tion of its muscular fibers cannot be satisfactorily made out. 
They cross and recross, as every examiner has found, in an 
almost inextricable manner. 

An attempt has been made to divide the muscular fibers 
into three layers, namely, (1) one in which the fibers take a 
longitudinal direction; (2) another wherein they are circular, 
and (3) a third in which they run obliquely. After patient 
study and research, Bayer arrived at the following conclusions : 
1. The fundus is composed of— 

(a.) A superficial layer, the medium longitudinal fibers of 
which pass from before backwards, while the lateral fibers are 
arranged in whorls around the insertions of the oviducts. 
These whorls pass from left to right around the right tube, from 
right to left around the left tube, compared with the direction 




Fig. 29. — Muscular fibers of un- 
impregnated Uterus (Farre). a, 
fibers united by connective tissue. 
b, separate fibers and elementary 
corpuscles. 



Internal Generative Organs. 



39 



in which the hands of a watch move. A hood-like covering is 
thus formed, probably arising from the external longitudinal 
layer of the oviduct, and of the round ligament. 

(b.) Of the deepest, or submucous layer, arranged in the 
same manner as the above, and derived from the internal 
longitudinal fibers of the oviduct. 

(c.) Of a middle layer, which is derived from the round and 
from the ovarian ligaments, a broad band, anteriorly and 
posteriorly, on both sides of the median line, passing in a sagit- 




Fig. 30.— External Muscular Fibers of the Uterus. 

tal direction. This is interlaced with transverse bands from 
the circular fibers of the oviducts. Fibers from the ovarian liga- 
ment, in connection with the latter, surround the horns of the 
uterus in spirals and obliquely placed circulars. 

2. The posterior wall is formed by the circular fibers of the 
oviduct, by diagonal lamellae from the ovarian ligament, 
which pass inwards from above, and, finally, by the eccentric 
rings coming from the retractors, which penetrate all the 
layers. In this description the most superficial and the deepest 
longitudinal fibers originating from the oviducts, and which 



40 



Anatomy of the Pelvis. 



unite to form anteriorly and posteriorly a triangular muscle, 
are omitted. 

3. The middle part of the anterior wall may be divided 
into an external longitudinal layer, which arises from the mus- 
cular fibers of the round ligament, united with the longitudinal 
fibers from the oviduct ; a middle layer "formed by the union of 
circular fibers from the oviduct with the anterior rings of the 
retractors, and an internal longitudinal layer formed by the 

crossing anteriorly of 
the inner longitudinal 
fibers of the oviducts. 

4. In the lower part 
of the body the greater 
part of the walls is 
formed by muscular 
bands from the round 
ligaments. 

5. In the internal 
and external portion of 
the cervix, longitudinal 
fibers, which are the con- 
tinuation of the corre- 
sponding layers of the 
corpus, anteriorly and 
posteriorly pass in the 
median line. Besides 
these, the posterior wall 
of the cervix essential- 
ly consists of eccentric 
rings of the retractors, 
the interlacing fibers of 
which form other parts, 

and finally of fasciculi from the ovarian ligaments, which after 
passing longitudinally are inflected. 

In the anterior wall of the cervix only muscular lamellae, 
running diagonally toward the mucous membrane, and cover- 
ing each other like the tiles of a roof, can be recognized ; the 
fibers of the retractors are found more especially in the lower 
third, forming a compact muscular mass from interlacing with 
the radiating fibers from the round ligament. 

The Mucous Surface.— -The existence of any mucous mem- 
brane whatever on the inner surface of the uterus has been 




Fig. 31. 



-Inner Muscular Fibers of the 
Uterus. 



-— 



Internal Generative Organs. 41 

questioned by a number, and even recently by Dr. Snow Beck, 
who insists that what has been so regarded is nothing more 
nor less than softened proper uterine tissue. Authorities in 
general, however, do not concur in this belief, but agree that it 
is essentially a mucous membrane, differing from mucous mem- 
brane in other parts chiefly in being more intimately asso- 
ciated with the subjacent structures, in consequence of possess- 
ing no definite connective tissue frame-work of its own. Its 
color is pale pink. Its thickness varies considerably in dif- 
ferent parts. Towards the middle of the body it constitutes 
about one-sixth of the thickness of the entire uterine walls, 
being from one-twelfth to one-twenty-fifth of an inch. Like the 
uterine walls themselves, it thins off rapidly towards the in- 
ternal os below and the Fallopian tubes above. Within the 
cervix the uterine mucous membrane loses many of its char- 
acteristics. On the anterior and posterior surfaces of the canal 
is a prominent perpendicular ridge, with one less distinct on 
each side, from which extend ridges at acute angles. These, 
from their appearance, have been called the arbor vitse, penni- 
form rugae, and palmae plicatse. Like the vaginal rugae, they 
are most distinct in virgins, and are indistinct after child- 
bearing;. The mucous surface of the uterus in a normal con- 
dition is covered with a thin layer of transparent alkaline 
mucus. 

The Uterine Glands. — With the aid of a strong glass, the 
general structure of the uterine mucous membrane is clearly 
seen. It is made up in part of connective tissue, which is 
directly continuous with the connective tissue of the muscular 
coat, in which, as a bed, are a large number of tubular, or 
utricular, glands. About forty-five of them are contained in a 
space one-eighth of an inch square. These glands have a sinuous 
course, often divide below into two or three separate blind ex- 
tremities, and are about ^h of an inch in diameter. As a rule 
they penetrate the entire thickness of mucous membrane, and 
in some instances even dip into the muscular tissue. Their 
basement membrane is composed of spindle-shaped cells, which 
dovetail into one another. Their free surface is covered with 
cylindrical cells, possessing cilige. The mucous membrane itself 
possesses an epithelial covering, of the ciliated variety, which 
is believed by some to produce a current in the direction of the 
Fallopian tubes. 

The glands of the cervix (glands of Naboth) cover the 



42 



Anatomy of the Pelvis. 



entire area of the cervical canal, from the internal os to the 
borders of the external. They differ from those found within 
the uterine cavity. Like them they are cylindrical, but termi- 
nate in a rounded cul-de-sac, lentil-shaped. These glands are so 
numerous that, according to Dr. Tyler Smith, "ona moderate 
computation, under a power of eighteen diameters, ten thou- 
sand mucous follicles are visible in a well developed nulliparous 
organ." " These glands," says Dr. Lusk, " are, genetically con- 
sidered, simple inversions of the mucous membrane, and are 
lined by ciliated epithelium." 

Obstruction of the neck of these 
glands gives rise to straw-colored vesi- 
cles, which have been called the ovula of 
Naboth. The penniform ruga^ give to 
the cervical canal an extensive secre- 
tory surface, which furnishes an alkaline 
mucus. 

The Vessels of the Uterus.— The ute- 
rus receives its blood from two sources, 
namely, (1) the two ovarian, or sper- 
matic, arteries, and (2) the two uterine. 
The origin of the ovarian arteries is 
about two and a half inches above the 
aortic bifurcation. They pursue a ser- 
pentine course, descending obliquely 
downwards under the peritoneum to the 
pelvic cavity, and then ascending be- 
tween the folds of the broad ligaments. 
They then reach by their main trunks 
the sides of the uterus, and communi- 
cate with the uterine arteries. The 
uterine arteries are derived from the 
hypogastric. Their course is at first to 
the vaginal fornix, where they give the "vaginal pulse." Thence 
they curve upwards between the folds of the broad ligament, 
and pass in a tortuous course over the lateral borders of the 
uterine cervix and body. By means of a circumflex branch at 
the junction of cervix and corpus uteri, the arteries of each side 
communicate. 

The veins of the uterus are valveless, but, by anastomosis, 
they form a network through all the uterine tissues. They are 
so intimately related to the latter that they remain open after 




Fig. 32. — Section 
through Uterus, show- 
ing cavity, a, and gland- 
ular structures, d. (He- 
ber.) 



Internal Generative Organs. 



43 



section. During pregnancy they enlarge to form "sinuses." 
The blood, collected by the veins, is carried into two venous 
plexuses, namely, the uterine and pampiniform. The latter 
returns blood from the uterus, Fallopian tubes and ovaries, 
but the former from the uterus only. 

The Uterine Nerves. — Frankenhaeuser says that the nerves 
of the uterus are derived from the gangliated cords of the sym- 
pathetic system, through the medium of the hypogastric and 
cervical plexus, and by means of which important connections 
are formed with all the ab- 
dominal viscera. The nerves 
supplied to the organ, when 
examined without the aid of a 
lens, are soon lost to sight in 
the uterine walls ; but in micro- 
scopic preparations, Franken- 
haeuser has traced their ulti- 
mate filaments to the muscu- 
lar element, where they appear 
to terminate in the nuclei of 
the fiber-cells. Notwithstand- 
ing the denial of some anato- 
mists, it is now generally con- 
ceded that the cervix is sup- 
plied with numerous filaments, 
even to the os tincse. 

From experiments on rats, 
mice, rabbits, etc., Rein con- 
cludes that there exists an 
essential nervous plexus, lying 
outside of the uterus, mainly 
in the cellular tissue surround- 
ing the vagina at the point 




Fig. 33. — Arterial Vessels m a 
Uterus ten days after Delivery. The 
posterior aspect is shown. 1, fundus 
uteri. 2, vaginal portion. 3 3, round 
ligaments. 4 4, Fallopian tubes. 5, 
right ovary. 6, abdom. aorta. 7, inf. 
mesenteric art. 8 8, spermatic ar- 
teries. 9, common iliac. 10, ext. 
iliac. 11, hypogast. art. 



where the hypogastric plexus 
anastomoses with filaments of 
the sacro-uterine nerves. Many ganglionic cells are found in 
it, lying for the most part along the course of the principal 
nerve branches which go to, and come from, the plexus. The 
upper limit of these cells is at the beginning of the tubes; the 
lower limit is lost in the vaginal plexus. No fiber, either from 
the hypogastric plexus or from the sacral nerves, goes to the 
uterus without first passing through the uterine plexus. 



44 



Anatomy of the Pelvis. 



The Lymphatics.— Lymph-spaces abound in the uterine tis- 
sues, and regular lymphatic vessels are found in the connective 
tissue about the arterial trunks in the parenchyma. Beneath 
the peritoneum is found a real network of these vessels. Large 
receiving vessels lie just beneath the external muscular layer on 




Fig. 34. — Nerves of the Uterus. A, plexus uterinus magnus. B. plexus 
hypogastricus. C, cervical ganglion. 1, sacrum. 2, rectum. 3, bladder. 
4, uterus. 5, ovary. 6. extremity of Fallopian tube. (Frankenhaeuser.) 

either side of the organ, into which the lymph from both the 
subserous and uterine vessels is poured. The lymphatics of the 
cervix pass to the glands of the pelvic cavity. 

Development.— In the embryo the uterus is formed by the 
fusion of the two ducts of Miiller, or the efferent tubes of the 



Internal Generative Organs. 



45 



Jw" "*! 




Fig. 35 —Uterus with double cavity, and slight deviation of form. 




Fig. 36.— Uterus Septus Bilocularis. Double uterus, with single vagina, 
seen from the front. Left walls more developed in consequence of preg- 
nancy. (Cruveilhier.) 



46 



Anatomy of the Pet, vis. 



rudimentary generative apparatus. Upon thus uniting, the 
partition between the two is absorbed, and the organ is then 
left but a single cavity. In differeDt stages of development 
there is accordingly an organ of varying shape. 

Abnormalities of the Uterus. — The various abnormal 
conditions of the uterus and vagina which are occasionally met 




v 
a 

Fig. 37. — Double Uterus and Vagina from a Girl Aged Nineteen (Ersen- 
mann). a, double vaginal orifice with double hymen, b, meatus urethrse. 
c, clitoris, d, urethra, e e, the double vagina. / /, uterine orifices, g g, 
cervical portions, h h, bodies and cornua. i i, ovaries, k h, Fallopian 
tubes. I I, round ligaments, m m, broad ligaments. (Courty.) 

are, in the main, the result of arrested development. After the 
canal or ducts of Muller have united to form the rudimentary 
uterus, if the partition should remain, the result will be a 
double or bifid uterus. This may be true of an organ present- 



Internal Generative Organs. 47 

ing little difference in form from that of the normal uterus, as 
shown in figure 35, or the organ may present an external ap- 
pearance which corresponds to its internal anomalies, as in 
figure 36. The partition may not exist alone in the uterine 
cavity, but extend downwards, to form a double vagina as 
well. 

The following constitute the main varieties of abnormalities : 
1. The Uterus Unicornis, or single-horned uterus.— In that 
case the organ presents but a single lateral half, and generally 
has but one Fallopian tube. 2. The Duplex Uterus.— Two dis- 
tinct uteri are produced, each of which represents a half of the 
normal uterus. 3. The Uterus Bicornis .— This results from par- 
tial union of the ducts of Muller, giving to the upper part of the 
organ two horns, divided by a furrow. 4. The Uterus Cordi- 
formis. — This, as its name indicates, presents the form of a heart 
as ordinarily represented on playing cards. 5. The Uterus 
Septus Bilocularis.— Union in this case is complete, but the 
septum persists as represented in figure 36. 



48 



Anatomy of the Pelvis. 



CHAPTER V. 

THE FEMALE INTERNAL GENERATIVE ORGANS— Continued. 

The Fallopian Tubes, or Oviducts.— These are the homo- 
logues of the vasa differentia of the male. They are the 
infundibula or ingluvies which take up and convey the ova from 
the ovaries to the uterine cavity, as well as transmit to the 
ovaries the fecundating principle of the male. They measure 
from three to four inches in length, and extend from the upper 
angles of the uterus to the ovaries. Their course is along the 
upper margins of the broad ligaments, being covered by peri- 




Fig. 38.— Ovary and Fallopian Tube, 
fimbriated extremity of the tube, p o, 



o d, Fallopian tube, 
parovarium. 



o, ovary, o a, 



toneum similarly to the uterus. They may justly be regarded 
as integral portions of the latter organ. The Fallopian tubes 
are trumpet-shaped, and terminate near the ovaries in a com- 
paratively broad, fringed end, called the fimbriated extremity, 
or morsus diaboli. This free extremity communicates with the 
peritoneal cavity. One of the fimbriae is attached to the outer 
angle of the ovary by a fold of peritoneum. It is supposed that 
during the menstrual nisus the fimbria? apply themselves 



Internal Generative Organs. 49 

firmly to the ovary, in order to receive the escaping ovule. 
These tubes are in the upper part of the broad ligament, where 
they can be felt as hard cords. The uterine extremity of the 
tube presents an opening known as the ostium uterinum, which, 
owing to its small size, will scarcely admit a bristle. 

The tubes are so remarkably movable that they are not 
only capable of applying themselves to those parts of their 
respective ovaries from which the ovule is to come, but, as is 
now believed, to stretch themselves to opposite sides to receive 
an escaping ovule. 

In some cases there are found to exist supernumerary fimbri- 
ated extremities which communicate with the tube at some 
distance from the main extremity. In the bodies of twenty 
women, selected at random by M. Gustave Kichard, this anom^ 
aly was found five times. 

The walls of the tubes are provided with a peritoneal, a 
muscular and a mucous coat,— the muscular predominating. 

The last is arranged in two layers— one longitudinal and 
the other circular. By virtue of these the tubes have a ver- 
micular or peristaltic action. Between the muscular and peri- 
toneal layers is a web of connective tissue, which gives support 
to a rich plexus of blood-vessels. The mucous membrane lining 
the cavity of the tube is highly vascular, and is provided with 
ciliated epithelium, which is said to produce a current in the 
direction of the uterus. 

The Ovaries.— These are regarded as the essential or- 
gans of generation in the female, since they provide the germ 
which is made fruitful by contact with the male fecundating 
principle. They are the analogues of the testes, and, up to the 
time of Steno, were called " testes mulieris.'' They are situated 
on either side of the uterus, within the pelvic cavity, and are 
attached to that organ by muscular bands about an inch long, 
called the ovarian ligaments. The t y are small, oval, flattened 
bodies, broader at the end distant from the womb, their mea- 
surements being about an inch and a half long, about three- 
quarters of an inch in breadth, and three-eighths to half an 
inch in thickness. They are situated between the layers of the 
broad ligaments, the posterior layer being reflected over the 
entire organs, save at the attached borders, at which points 
openings exist for transmission of the spermatic vessels. They 
lie beneath, and somewhat behind, the fimbriated extremities 
of the Fallopian tubes. 

(4) 



50 



Anatomy of the Pelvis. 



Besides the peritoneal coat, they have beneath it another, 
the tunica albuginea. This covering is so intimately adherent 
to the subjacent tissues that it cannot be stripped off. In the 
first three years of life it is entirely absent. 

Beneath the albuginea the parenchyma of the organ has an 
outer cortical and an inner medullary substance. The former 
is of grayish color, and is made up of interlaced fibers of con- 
nective tissue, contain- 
ing a large number of 
nuclei. It is in this 
structure that the 
Graafian follicles and 
ovules are found. The 
latter exist in immense 
numbers in various 
stages of development, 
from the earliest peri- 
ods of life. The stro- 
ma of the cortical sub- 
stance is at no place 
sharply distinguished 
from that of the me- 
dullary. The medul- 
lary substance has a 
reddish color, given it 
by its numerous ves- 
sels. It consists of 
loose connective tissue, 
with some elastic, and 
muscular. Rouget and 
Kis claim that the 
greater part of the 
ovarian stroma is 
formed of muscular 
tissue. 

The Gkaafian Fol- 
licles, or Ovisacs —The Graafian follicles are formed at an 
early period in foetal life, by cylindrical indigitations of the 
epithelial covering of the ovary, which sink into the sub- 
stance of the gland. Portions in this manner become infolded 
from the rest of the tubules, and form the Graafian follicles. 
The ovules are developed from the epithelial cells which 




Fig. 39. — Longitudinal Section of an 
Ovary from a Girl Eighteen Years Old. 1, 
albuginea. 2, fibrous layer of cortical por- 
tion. 3, cellular layer of cortical portion. 4, 
medullary substance. 5, loose connective 
tissue. 



Internal Generative Organs. 



51 



line the tubules, derived primarily from the surface of the 

ovary. 

The number of the Graafian follicles is immense, the ovary 
at birth being estimated by Foulis to contain not less than 
30,000, and by Henle 36,000. The ovary at birth contains its 
full quota of follicles, and, during the menstrual epoch, develop- 
ment and destruction are constantly going on. Of course, but 




Fig. 40. — Portion of Vertical Section through Ovary of Bitch, a, epi- 
thelium of ovary, b b, tubules of ovary, c, young follicles, d, mature fol- 
licles, e, discus proligerus, with ovum. /, epithelium of second ovum in 
same follicle, g, tunica fibrosa folliculi. h, tunica propria folliculi. i, mem- 
brana granulosa. (Waldeyer.) 

a small proportion of the entire number ever reach maturity. 
Few of these follicles are visible to the naked eye, but under the 
microscope all come plainly into view. 



52 



Anatomy of the Pelvis. 



The structure of a mature Graafian follicle is, 1, an investing 
membrane, consisting of two layers. The external, or tunica 
fibrosa, is formed of connective tissue, and is highly vascular. 
The internal, or tunica propria, is also composed of connective 
tissue, but contains a large number of fusiform cells and 
numerous oil globules. These two layers are really formed of 
condensed ovarian stroma. 2, The membrana granulosa, con- 
sisting of stratified columnar epithelial cells. Near the cir- 
cumference of the ovisac is the ovule, around which are 
congregated a large number of epithelial cells, forming what is 
known as the discus proligerus. Transparent fluid fills the 
remainder of the follicle, with three or four bands, or retinacula 
of Barry, stretching through it, and attached to the opposite 

walls of the cavity. In some 
young follicles the ovule fills 
the entire cavity. 

The Ovule. — The ovule is a 
rounded vesicle, about ih of 
an inch in diameter. At the 
time of its discharge from the 
ovary it is no longer a simple 
cell, composed of ordinary pro- 
toplasm, but presents the fol- 
lowing characteristics: It has 
a thick, transparent envelope, 
termed the vitelline membrane, 
or zona pellucida. The body 
of the cell is the vitellus, or 
yolk. It possesses the proper- 
ties of ordinary protoplasm, 
has a viscid consistence, and is 
opaque from the presence of very fine granules and globular 
vesicles. The nucleus of the cell becomes converted into a 
large, clear, colorless vesicle, called the germinative vesicle. 
The nucleolus persists as a dark, probably solid body, within 
the germinative vesicle, where it is known as the germinative 
spot. The ovule is attached to some part of the internal sur- 
face of the Graafian follicle. 

Vessels and Nerves of the Ovary— The arteries of the 
ovary, derived from the internal spermatic, enter at the hilum 
and penetrate the medullary substance in a spiritual course. 
The branches freely anastomose, and form an interlacement. 




Fig. 41. — Diagrammatic section 
of Graafian Follicle. 1, ovum. 2, 
membrana granulosa. 3, external 
membrane of Graafian follicle. 4, its 
vessels. 5, ovarian stroma. 6, cavity 
of Graafian follicle. 7, external cov- 
ering of ovary. 



Internal Generative Organs. 



53 



Between the vessels thus connected are spaces, which become 
smaller as they approach the surface of the gland. The veins 
begin as radicals, rapidly enlarge, anastomose and form an 
erectile plexus. Larger veins then convey the blood through 
channels following the arteries, to the internal spermatic vein. 

Lymphatics emerge at the hilus, and are conducted to 
the lumbar ganglia. 

The nerve supply is from the ovarian plexus. 

The Intra-Pelvic Muscles.— Certain muscles which encroach 
upon the pelvic space should be mentioned. The iliac muscles 
spread over the entire iliac fossae, but their origin is chiefly 
marginal. The muscles condense below, pass under Poupart's 
ligaments, and become united to the psose muscles. These 
muscles cushion the iliac fossae, and thereby afford a soft 




Fig. 42. — Uterine and Utero-ovarian Veins (Plexus Papiniformis). 1, 
uterus seen from the front ; its right half is covered by the peritoneum ; 
upon the left half may be seen the plexus of utero-ovarian veins (internal 
spermatic). 6, utero-ovarian vessels covered by peritoneum. 7, the same 
vessels exposed. 8 8 8, veins from the Fallopian tube. 9, venous plexus 
of the hilum ovarii. 10, uterine vein. 11, uterine artery. 12, venous plexus, 
covering the borders of the uterus. 13, anastomoses of the uterine with 
the utero-ovarian vein (int. spermatic). 

support for the gravid uterus. The great psose and the iliac 
muscles encroach more or less upon the transverse pelvic diam- 
eter at the brim. By virtue of their femoral insertions, they 
serve as flexors of the thigh ; while, in addition, the iliacs act 
as abductors, and the psose as flexors of the pelvis upon the 
spinal column. 

The pyriformis muscles close the sacro-sciatic notches. 
Their shape is triangular, the base presenting a series of digita- 
tions, which find insertion upon the lateral portions of the 
anterior surface of the sacrum, and the superior margin of the 
sacro-sciatic ligament. After crossing the greater sacro-sciatic 



54 



Anatomy of the Pelvis. 



foramen, and emerging from the pelvis, they terminate in 
a tendon which is inserted into the great trochanters. 

The obturator internus muscle arises from the circumference 
of the obturator foramen, and the inner surface of the obturator 
membrane. Its converging fibers form a tendon, which passes 
out through the lesser sacro-sciatic foramen, and is inserted 
into the digital fossa of the great trochanter. None of the 
intra-pelvic muscles occupy much space in the pelvic cavity. 

The Mammary Glands.— An account of the female genera- 
tive organs would be incomplete without supplementary refer- 
ence to the mammary glands. They are two in number of 



SACRm 




PYRAMIDALIS.HI 



Fig. 43. — Section of Pelvis, showing the Pyramidal Muscles. 

the compound racemose variety, are situate on either side of 
the sternum, between two layers of superficial fasciae, over the 
pectoralis major muscles, and extend from the third to the sixth 
rib. They are convex anteriorly, and flattened posteriorly. 
Their size varies considerably, chiefly on account of the differ- 
ence in amount of adipose tissue which they contain. In most 
women the right breast is larger than the left. Owing to hyper- 
trophy of their glandular structures, during pregnancy they 
increase greatly in size. Anomalies in number, shape and posi- 
tion are occasionally observed. They are covered with a fine, 
supple skin, and a layer of adipose tissue, which increases in 
thickness towards the periphery. The glandular mass is made 
up of from fifteen to twenty-four lobes, these being subdivided 
into lobules, constructed of acini, or minute cul-de-sacs. The 
acini open into fine canaliculi, which unite until they form a 



Internal Generative Organs. 



55 



large duct for each lobule. These ducts are confluent, forming 
a still larger canal for each lobe, which opens on the surface of 
the nipple. The latter canals are known as galactophorus, or 
lactiferous ducts. When they reach the space beneath the 
areola they enlarge to form the sinus of the duct, measuring 
from one-sixth to one-third of an inch in diameter. In the 
nipple, their diameter is from one-twelfth to one-twenty-fifth of 
an inch. The openings on the nipple are from one-sixtieth to 
one-fortieth of an inch in diameter. The acini are lined with a 
single layer of small polyhedral cells, becoming more cylindrical 




Fig. 44. — Supernumerary Mammse. (Charpentier.) 

near the canalicular ducts. The main channels are lined with 
low, cylindrical cells, and are provided with non-striated mus- 
cular fibers, which contract and produce a freeflow of the secre- 
tion during lactation. 

At the summit of the mamma is a conical projection, vary- 
ing in diameter from a quarter to half an inch, called the nip- 
ple. Its surface is covered with papillae, between which open 
the lactiferous ducts. Upon its surface open also numerous 
sebaceous follicles, the secretions of which protect and soften 
the integument during lactation. Beneath the skin are mus- 
cular fibers, mixed with connective and elastic tissues, vessels, 
nerves and lymphatics. Irritation of the nipple brings about 
turgescence and excites muscular action, which causes contrac- 
tion and hardening. 



56 



Anatomy of the Pelvis. 



The Areola is a circle which surrounds the nipple, of a color 
differing from the other integument. It is pink in virgins, and 
is provided with from fifteen to thirty follicles, which pour out 
their secretions to moisten the areola. A band of muscular 
fibers is found beneath the integument, the action of which, 




Fig. 45. — Mammary Gland, a, nipple, the central portion of which is 
retracted, b, areola, c c c c c, lobules of the gland. 1, sinus, or dilated 
portion of one of the lactiferous ducts. 2, extremities of the lactiferous 
ducts. (Liegeois.) 

when stimulated, is to compress the lactiferous ducts, and thus 
favor the flow of milk. 

The mamma? receive their blood supply from the internal 
mammary and intercostal arteries, and are provided with lym- 
phatics, which open into the axillary glands. 

The nerves are derived from the intercostal and thoracic 
branches of the brachial plexus. 



PART II. 
PREGNANCY. 



CHAPTER I. 

IMPREGNATION AND DEVELOPMENT OF THE OVUM. 

Inasmuch as this branch of obstetrics is of theoretical 
rather than practical value to the student of widwifery, and 
since the study of it has been diligently pursued by a few, under 
most favorable conditions, and the results of their investiga- 
tions have been made the common property of the profession, 
the author has taken the liberty to draw freely from various 
authorities on the subject, sometimes in their own words, with- 
out, in every instance, giving explicit credit. 

The anatomy of the ovary with its Graafian follicles and 
ovules has already been given. The formation of the Graafian 
follicles is in the main completed during the ante-natal period 
of existence. Until about the time of puberty they remain in a 
quiescent state, but with its advent they begin to assume func- 
tional importance. The surface of the ovary, when now exam- 
ined, is found to be no longer smooth, but studded with 
small elevations. These elevations are caused by the enlarged 
Graafian follicles, which have approached the peripherj^, and 
being distended by their fluid contents, form rounded, translu- 
cent prominences. From disappearance of the blood-vessels 
and lymphatics at the point of pressure, a weak spot in the 
wall of the follicle is formed, called the macula or stigma fol- 
liculi. The discharge of the ovum is due to the conjoint action 
of a fatty degeneration of the walls of the mature follicle, and 
the development of the following changes: The follicle becomes 
congested, and the vessels coursing over it loaded with blood, 
while, at the same time, the ovarian covering becomes so thin 
that the elevation presents a bright red color. Laceration of 
some of the capillaries in the inner coats takes place, and 
a certain quantity of blood escapes into the cavity of the folli- 
cle. By these means the distension is greatly increased, until 
at last, under the additional stimulus of sexual excitement, or 

(57) 



58 Pregnancy. 

without it, rupture occurs, and the ovule is set free. Whether 
laceration takes place before, during or after menstruation is 
still an unsettled question. Thinning of the follicular and 
ovarian walls goes on at one and the same time, and final 
rupture takes place simultaneously. It is probable that lacera- 
tion is further promoted by growth of the internal layer of the 
follicle, which increases in thickness before rupture, and is given 
a characteristic yellow color by the number of oil-globules 
which it contains. Contraction of the muscular fibers in the 
ovarian stroma is also supposed to have an influence in 
the production of laceration. As rupture occurs, the fimbriated 
extremity of the Fallopian tube is closely applied to the ovary, 
receives the freed ovule, and starts it on towards the ute- 
rine cavity. 

The Corpus Luteum of Menstruation.— At the moment 
of rupture or immediately after it, an abundant hemorrhage 
takes place from the vessels of the follicle, by which its cavity 
is filled with blood. The blood soon coagulates and the clot is 
retained. The aperture through which the ovule escapes is 
often not more than one-fortieth of an inch in diameter. If the 
follicle is now incised longitudinally, it will be seen to form a 
globular cavity, one-half to three-quarters of an inch in diame- 
ter, containing a soft, dark coagulum lying loosely within it. 
An important change soon begins. The clot contracts and 
expresses its serum, which latter is absorbed by the neighbor- 
ing parts. The coloring matter of the blood is also to a great 
extent absorbed, so that at the end of two weeks a diminution 
of color is perceptible. The membrane of the follicle becomes 
thickened and convoluted, and encroaches on the cavity. At 
the end of three weeks the follicle has become so solidi- 
fied that, from its color, it receives the name of corpus 
luteum. It still continues in relation with the ruptured spot 
on the surface of the ovary, traces of which yet remain. On sec- 
tion at this time it presents the appearance of a convoluted 
wall and a central coagulum. The coagulum is semi-transpa- 
rent, of gray, or light-greenish color, more or less mottled with 
red. The wall is about one-eighth of an inch thick, and of yel- 
lowish or rosy hue. The entire corpus may be easily enucleated 
from the ovarian tissues. After the third week active retro- 
grade changes begin. The whole body undergoes a process of 
partial atrophy, until at the end of the fourth w^eek it is not 
more than three-eighths of an inch in its longest diameter. The 



Development of the Ovum. 59 

color also of its walls has now changed to a clear chrome yel- 
low. After this period the process of atrophy and degeneration 
goes on rapidly, until at the end of eight or nine weeks the 
whole body is represented by an insignificant cicatrix-like spot, 
less than a quarter of an inch in its longest diameter, in which 
the original texture of the corpus luteum can be recognized 
only by the peculiar folding and coloring of its constituent 
parts. It disappears entirely in seven or eight months. 

The Corpus Luteum of Pregnancy.— The foregoing shows 
that the mere presence of the corpus luteum is no evidence that 
pregnancy has existed, but only that a Graafian follicle 
has been ruptured and an ovule discharged. There is a 
difference between the corpus luteum of pregnancy and that of 
menstruation, and yet the difference is not essential or funda- 
mental. It is, properly speaking, only a difference in the 
degree and rapidity of their development. It will not be neces- 
sary, therefore, to enter upon a lengthy description of the ap- 
pearances and changes, but only to note some of the more 
salient points. At the end of the first month, the convoluted 
wall is bright yellow, and the clot still reddish. At the expira- 
tion of two months, instead of being reduced to the condition 
of an insignificant cicatrix, it is seven-eighths of an inch in di- 
ameter. When six months have passed it is still as large as 
before; the clot has become fibrous and the convoluted wall 
paler. At the end of utero-gestation, it is about half an inch in 
diameter ; the central clot is but a radiating cicatrix, and the 
external wall is tolerably thick and convoluted, but has lost its 
bright yellow color. The corpus luteum of pregnancy is often 
termed the true and that of menstruation the false. 

The Migration of the Ovum.— But a small portion of the 
ova in each ovary ever meet with the conditions requisite for 
fruition. Many ignobly perish in the ovarian stroma., while 
others, as we learn from the occurrence of extra-uterine preg- 
nancy, are doubtless lost in the abdominal cavity. 

The precise conditions which determine the passage of the 
ovum through the oviduct to the uterine cavity, are still 
shrouded in obscurity. The theory that by virtue of its 
erectility the Fallopian tube at the proper moment is brought 
into relation with the ovary through its fimbriated extremity, 
is open to criticism, since it has been demonstrated that the 
tube is not possessed of erectile tissue. Rouget found that in- 
jection of its vessels after death did not communicate to it the 



60 Pregnancy. 

slightest change of form or place. Experiments upon the mus- 
cular fibers of the tubes has brought no better results, as gal- 
vanization produced only vermicular contradictions, which did 
not affect the position of the fimbriae. Moreover, when we reflect 
on the situation and surroundings of these tubes, it becomes 
difficult to understand how it is possible for them to execute 
any extended movements. The theory advanced by Henle that 
the ovum is drawn into the Fallopian tube by currents pro- 
duced in the serum by the ciliated epithelium, which covers 
both the external and internal surfaces of the fimbria?, appears 
to be gaining favor. Failures of the ovum to enter the tube are 
probably common. 

While the ovum is in the outer portion of the tube, progress 
is presumed to be made by aid of the cilia?; but when further 
advanced on its way to the uterus, additional force is supplied 
by the circular muscular fibers. 

Fecundation. — Conception, fecundation, and impregnation, 
are terms all of which imply fruitful contact of the male and 
female elements, so that a new organism comes into existence. 
The precise point at which this takes place has been the subject 
of much speculation and research. It has been pretty clearly 
demonstrated that it cannot be within the uterus, inasmuch 
as it takes the ovum a period exceeding ten days to reach the 
uterine cavity, and an unfecundated egg cannot sustain life for 
so long a time. Abdominal pregnancies seem to prove the pos- 
sibility of fecundation at the ovary. But, when we reflect upon 
the rarity of such pregnancies, and the strong probability of 
the frequent failure of the escaped ovum to enter the Fallopian 
tube, we are led to infer that fecundation at the ovary is 
anomalous. Henle has directed attention to the fact that the 
outer part of the tube, possessing arborescent folds, is espe- 
cially designed as a receptacle for the seminal fluid. The con- 
gested condition of the mucous membrane, its canalicular 
structure, and the contractions of its muscular fibers, all seem 
intended to further the intimate contact of the spermatozoa 
with the ovum after it has reached this situation. 

The fecundating principle of the male is secreted in the testes 
at puberty, and is called the semen, or seminal fluid. During 
sexual congress the semen is ejaculated with considerable force 
by the fibers of the vasa differentia, and the special muscles 
which surround the vesiculae seminales and the prostate gland. 
It thus reaches the upper part of the vagina, and doubtless 



Development of the Ovum. 61 

sometimes even the cervical canal, from which situation the 
spermatozoa ascend to the point of contact with the female 
ovum. It is, however, an established fact that deposit of the 
seminal fluid deep in the vagina is not essential to impregna- 
tion, for pregnancy has been found co-existent with imper- 
forate hymen. 

The semen is a thick, glutinous, whitish, albuminous fluid, 
heavier than water, and emitting a characteristic odor. When 
placed under a powerful lens it is found to contain small, 
oval, flattened bodies, measuring not more than -^Vo 
of an inch in diameter, provided with tails which taper 
gradually to the finest point. The entire spermatozoon meas- 
ures from -^-q to 4^ of an inch. These bodies do not pass- 
ively float in the seminal fluid, but move about with a lashing, 
undulating motion, as though endowed with volition. The ap- 
pearance of independent life, which they manifest, was what led 
Kolliker to compare them to ciliated cells, and gave the erro- 
neous impression that they were animalcules. The name sperma- 
tozoa, which they bear, is suggestive. Henle, who has given 
much study to the subject, has estimated their speed at an inch 
in seven-and-a-half minutes. It is doubtless to the spermatozoa 
that the semen owes its fecundating power. Xor is this faculty 
speedily lost, for examination has demonstrated the vitality 
and activity of these bodies within the female generative 
organs, eight and ten days after reception. If then the sperma- 
tozoa are absent from the seminal fluid, as in debility or old 
age, impregnation is impossible, and it is their absence from 
the seminal fluid of hybrids which renders these animals sterile. 

Our knowledge of the process of fecundation is very limited, 
the fact only being known that the spermatozoa penetrate the 
vitelline membrane, and then dissolve in the vitellus. Observa- 
tions on the lower animals appear to prove that penetration of 
the ovule by one spermatozoon is not only adequate, but con- 
stitutes the usual order. Others may gather about, and pene- 
trate a certain depth, but one only enters the protoplasm and 
creates the vital contact. Various theories of penetration 
have been advanced. Barry was the first to discover sperma- 
tozoa within the zona pellucida of the rabbit's ovum ; and his 
discovery has since been confirmed. Hensen found that the 
spermatozoa began to penetrate the rabbit's ovum about thir- 
teen hours after coitus. 

Barry also discovered an opening in the zona pellucida, 



62 



Pregnancy. 



seemingly designed as a point of entrance for the spermatozoa ; 
and Kebler confirmed the discovery. 

Bobin, who made some very interesting and instructive 
observations upon the ova of the nephelis vulgaris, or common 
leech, found that the spermatozoa, in their movements around 
the ovum, assumed a perpendicular or oblique direction to the 
vitelline membrane. At one point penetration of this membrane 
could be distinctly observed. At the end of an hour the pene- 
tration had ceased, and then a little bundle of spermatozoa 
could be seen arrested, partly within and partly without the 
ovum. They continued to move in the clear, limpid fluid sur- 
rounding the vitellus, for a time, but after fifteen or twenty 
minutes their movements grew slow, and in about two hours 
had altogether ceased. It was then found, by counting the 
number remaining and comparing it with that of the sperma- 
tozoa which entered, that some had 
disappeared. They had been ab- 
sorbed directly into the vitellus, to 
serve for its fecundation. 

Course of Spermatozoa to 
Point of Fecundation. — The 
movement of the spermatozoa 
through the uterus and Fallopian 
tube is probably effected by various 
agencies. First: By the undulatory 
motions of the spermatozoa them- 
selves, although it is difficult to 
comprehend why these should propel them in any definite 
direction. Secondly: By the action of the cilia of the epithe- 
lium lining the passages. Thirdly : By muscular peristaltic con- 
tractions. "It is probable," says Hirst, "that once the sper- 
matozoa have reached the neighborhood of the ovum their 
movements are controlled by some substance excreted by the 
egg and diffused in the liquid bathing it. In some of the lower 
plants (ferns and others) the male elements are motile anthero- 
zoids ; if a capillary tube containing a weak solution of malic 
acid be immersed in water containing antherozoids, the latter 
swim towards the opening of the tube. The malic acid, slowly 
diffusing through the water, controls the movements of the an- 
therozoids,. so that their cilia lash in a manner tending to drive 
them to the place where there is most malic acid. It has also 
been found that malic acid is excreted by the female organs of 




Fig. 46. — Spermatozoa. 



Development of the Ovum. 



63 



these plants. Some similar process may occur in the higher 
animals and lead to a swarming of spermatozoa around the 
egg." It is highly probable that their usual course is not 
through the channel said by Mauriceau, De Graaf, and others, 
to exist in the uterine walls. 

Changes in the Ovum After Fecundation.— It should be 
premised that our knowledge of what takes place in the ovum of 
the human female is derived mainly from analogy; but from the 
studies in comparative physiology diligently prosecuted by a 
few, it is quite probable that the changes described in the fol- 
lowing pages are worthy of credence. 

One of the earliest changes which has been observed is the 
disappearance of the germinal vesicle. This may occur, how- 
ever, whether fecundation has taken place or not ; but, in an 




Fig. 47. — Bifurcation of Tubal Canal. (Hennig.) 

impregnated ovum, the embryo cell is formed in its place. 
Inasmuch as the entire time consumed in the migration of the 
ovum to the uterine cavity is upwards of ten days, it is 
assumed that some of these changes take place while yet it 
occupies the outer third of the Fallopian tube. In this part of 
the oviduct the zona pellucida becomes somewhat thickened, 
the germinal spot disappears, and its place is supplied by the 
embryo cell, while the vitellus becomes somewhat condensed. 
Before the egg enters the uterine cavity, more remarkable 
changes begin by segmentation, or cleavage of the yolk. Their 
first step is the formation of a deep furrow, which, by extension, 
soon completely divides the yolk. These halves are likewise 
divided by a similar process, so that four spheres result. Nor 
does the segmentation stop here, but it goes on until the entire 
yolk has been converted into a finely granular mass, resem- 



64 



Pregnancy. 



bling in that particular the mulberry. It should be understood 
that this segmentation also includes the embryo cell, or 
nucleus, so that every granular cell resulting from the sub- 
division retains the elements of the original vitellus. From 
this germ morula, or mass, the whole organization of the 
embryo is gradually evolved. These cells grow in many dif- 
ferent ways; some elongate into fibers, others remain spherical; 
"some excrete around them a large amount of intercellular 
substance and make cartilage, bone, and connective tissue; 
others make little intercellular substance. In some of them 
contractility of the original egg-protoplasm is intensified and 
they become muscle-fibers. Others become so modified in struc- 
ture that they almost or quite lose the contractile power pos- 
sessed by the ovum, but developing to a high degree its irrita- 
bility, or faculty of being easily changed by external influence, 






Figs. 48, 49 and 50. — Successive stages of Segmentation of the Yolk. 



they become nerve-cells or the end-organs of nerve-fibers in the 
retina and other sense apparatuses. Some cells become dis- 
tinctly secretory, others excretory ; some become horny, and 
as epidermis, hairs, and nails, serve to protect the organism. 
The genera] result is that from a set of similar cells, formed by 
the division of a single cell, the oosperm, there is developed 
that heterogeneous mass of groups of cells, each with distinc- 
tive modes of growth and with special physiological properties, 
which constitutes the tissues and organs of the adult human 
body." The whole process of segmentation is completed in the 
rabbit within about seventy hours. 

Now begins another important change. A clear fluid accu- 
mulates in the center of the mass, and gradually increases in 
quantity, until a greater part of the original cells become flat- 
tened and closely crowded to the surface. We then have a vesi- 
cle, called the blastodermic vesicle, and the flattened cell wall 
is known as the blastodermic membrane. It is found now that 



DevelopmExNT of the Ovum. 



65 



by absorption, the dimensions of the ovum have been increased 
from a diameter of-gV to -^ of an inch. 

All the cells formed by the original segmentation do not 
take part in the formation of the blastodermic membrane. 
Those which are left accumulate and lie together at one spot 
just beneath the membrane, where by peripheral extension 
they gradually spread over and line the inner surface of the 
blastodermic membrane, thereby providing for it a second, or 
sub, layer. The outer layer of the blastodermic membrane is 
accordingly termed the ectoderm, and the inner layer the ento- 
derm. The zona pellucida is now called the chorion, and there 
is formed between it and the blastodermic membrane a thin 
film of fluid. During the formation of the entoderm, a bright 
round spot is observed in the 
ectoderm, which, as farther ob- 
servation shows, marks the place 
at which all the more important 
processes connected with embry- 
onic development take place, and 
is termed the area germinativa. 
This is formed by an aggrega- 
tion of the original segmentary 
cells. It at first presents a homo- 
geneous appearance, but there 
soon develops in its center a 
clear space, called the area pel- 
lucida, bounded by a dense layer 
of cells. The area pellucida, at 
first circular, becomes oval, and there forms in its center a dark 
oval spot, termed the embryonic spot. A longitudinal furrow, 
or shallow groove, which has been termed the primitive trace, 
the borders of which are called the dorsal plates, then makes 
its appearance in the embryonic spot, constituting the earliest 
indication of the cerebro-spinal canal. 

A third intermediate cell-layer has meanwhile formed, called 
the mesoderm, lying between the ectoderm and the entoderm. 
In this layer are developed the primitive blood-vessels, which, 
as they develop, give to the area germinativa the name of area 
vasculosa. Later the mesoderm divides into two distinct 
layers, giving to the embryonic structures, at one stage, four 
distinct layers. 

Briefly, it may be said that the ectoderm is concerned in 
(5; 




Fig. 51.— External Surface of 
the Ovum, with Area Germinativa. 



66 



Pregnancy. 



the formation of the epidermis, hair, nails, the glandular struc- 
tures of the skin, the brain, the spinal cord, the organs of special 
sense, and, it is commonly supposed, the genito-urinary system. 
The outer stratum of the mesoderm gives origin to the corium, 
the muscles of the trunk concerned in moving the body, 
and the skeleton. The inner layer of the mesoderm provides 
the muscular and fibrous tissues of the digestive tract, the 
blood, the blood-vessels and the blood-glands. The entoderm 
supplies the epithelium lining the walls and glands of the 
intestines. 

When a transverse section of the primitive trace is placed 
under a microscope, its characters are readily recognized, 
while beneath the furrow a cylindrical organ known as the 





chorda dorsalis may be seen. It is about this structure that 
the vertebrae eventually form. The latter bodies themselves 
are derived from two longitudinal chords, separated by a 
cleavage from the portions of the intermediate layer next 
to the chorda dorsalis on either side. The peripheral portions 
of the mesoderm then become the lateral or abdominal plates. 
The dorsal plates continue their development until they meet 
in the median line, forming a tube known as the tubus medulla- 
ris, the cavity within which is ultimately elaborated the central 
nervous system. 

The mesoderm, which at this point has been fused into a sin- 
gle'layer, now separates into two* strata united by their inner- 
borders, and thereby forms what are known as the mesenteric 
folds. The opposite extremities of the inner stratum of 'the 
mesoderm curve inwards, and finally unite to form the intestine. 



Development of the Ovum. 



67 



while at the same time they enclose the entoderm. The closure 
in this case is from front to rear, as well as from side to 
side, but does not include the entire blastodermic vesicle, a con- 
siderable portion of which, called the umbilical vesicle, during the 
early months is connected to the body of the embryo. Finally 
the ectoderm and the outer stratum of the mesoderm curve 
forwards and inwards to inclose a long cavity which sur- 
rounds the intestines. This cavity is eventually divided by 
the diaphragm into the thorax and the abdomen. 

The embryo as thus far formed gradually moves towards the 
center of the ovum, while there rises about it, on every side, 
folds made up of the ectoderm and the outer layer of the 
mesoderm. Between the latter and the inner stratum is 
a collection of fluid. The process of depression goes on, and 
the folds of the ectoderm, now called the amniotic folds, ap- 
proach closer and closer, 
until eventually they meet. 

The partitions are subse- 
quently broken down, and 
there is formed a cavity 
called the amniotic cavity, 
with its outer sac known as 




Fig. 54. — Showing Amnio - chorial 
Pocket of False Waters. 



the amnion. This cavity 
fills with fluid commonly 
spoken of as " the waters" or liquor amnii. 

Between the chorion and amnion is often found a gelatinous 
fluid, traversed by minute filamentous processes, called the 
vitriform body, or corpus reticule. It sometimes exists in con- 
siderable quantity, and near the end of pregnancy may be dis- 
charged by rupture of the decidua and chorion, and thereby 
give rise to the supposition that the waters (liquor amnii) have 
escaped. 

Sources of Nourishment — The ovum, during its passage 
through the Fallopian tube, is increased in size by absorption, 
from y^ of an inch to from -^ to 2V of an inch. When once 
lodged within the cavity of the uterus, the ovum begins to 
draw its nourishment from the mucous membrane lining that 
organ, at first by mere absorption through its walls, and later 
through the utero-placeutal circulation. The structure previ- 
ously alluded to as the umbilical vesicle, lined by the entoderm, 
and covered by the inner stratum of the mesoderm, doubtless 
contributes to embryonic nourishment. Its cavity, which at 



68 



Pregnancy. 



first communicates with the intestine, soon becomes separated 
by obliteration of its passage, but remains attached to the in- 
testine by a pedicle. In order to obtain a clear idea of foetal 
nutrition and of preceding embryonic development, it becomes 
necessary to enter into a more intimate acquaintance with 
certain structures to which allusion has already been made. 
The Chorion. — The chorion is the external membrane which 
envelops the ovum. Originally it consists, as elsewhere stated, 
of the vitelline membrane, or zona pellucida. Soon after the 
ovum enters the uterus, this part develops amorphous villi 
which serve to anchor the ovum to the uterine mucous mem- 
brane. When once the 
amnion has been formed 
by a meeting of the folds 
of the blastodermic mem- 
brane over the back of the 
embryo, and an absorp- 
tion of the partitions be- 
tween them, the outer layer 
of the blastoderm for a 
time remains in relation to 
the existing chorion; but 
the latter, so far as it is a 
vestige of the zona pel- 
lucida, disappears, and a 
new chorion, as it were, is 
formed from the ectoderm. 
The new chorion in turn 
becomes covered with a 
growth of non-vascular villosities, which are not solid but 
hollow. These villi develop rapidly in size and number, by a 
process of gemmation, so that at the close of the third week 
the entire ovum presents upon the outer surface its character- 
istic shaggy appearance. 

The Allantois.— During the third week a new organ is 
developed, by means of which provision is made for supplying 
the rapidly increasing nutritive demands of the embryo. This 
organ, which establishes vascular connection between the 
embryo and chorion, is termed the allantois. It begins as a 
sac-like projection from the posterior extremity of the intes- 
tine, while yet the umbilical vesicle is an organ of considerable 
size. It is composed of two layers derived from the entoderm, 




Fig. 55. — Human Embryo at the third 
week, with Villi of the Chorion. 



Development of the Ovum. 



69 




and the inner layer of the mesoderm, which soon unite to form 
one membrane. At first it is provided with two arteries and 
two veins, but later the vein on the right side becomes oblite- 
rated. These are the same vessels which are afterward found 
in the fully developed umbilical cord. Before the close of the 
fourth week the allantois reaches the chorion, and then begins 
to spread upon it and form a vascular lining. The chorion 
and allantois now become fused iuto a single membrane, and 
constitute the permanent chorion, the outer surface of which 
is called the exochorion, and the inner the endochorion. Dur- 
ing the development of the allantois the umbilical vesicle 
diminishes rapidly in rela- 
tive size, until at the end 
of the sixth week it is no 
larger than a pea. 

As development of the 
ovum advances, its sur- 
face becomes less and less 
vascular, except near the 
place where the allan- 
tois originally anchored 
to the chorion, and there 
vascularity is rapidly in- 
creased. At other places 
the villi of the chorion 
also atrophy and disap- 
pear, until, after a time, 
the greater portion of 
the ovum becomes bare, 
while the remainder re- 
tains its villi in full devel- 
opment. Thisis the site at which the placenta ultimately forms. 

The Decidua. — The decidua is composed of three distinct 
portions, namely, the decidua vera, the decidua refiexa, and 
the decidua serotina. The decidua vera (or uterine decidua) is 
nothingmore nor less than the altered mucous membrane lining 
the uterine cavity. The decidua refiexa (ovular or epichorial 
decidua) is a structure formed from the uterine mucous mem- 
brane, which, when completed, closely envelops the ovum. 
Between these two portions there is at first, over a greater part 
of the surface, a decided interspace filled with viscid, opaque 
mucus; but after a certain degree of development has been 



Fig. 56. — Formation of the Decidua 
Refiexa. (First stage.] 



^iw^ 




^^ 



Fig. 



57. — Formation of the Decidua 
Refiexa completed. 



70 



Pregnancy. 



attained, the enlarged ovum brings the two surfaces into close 
contact. The decidua serotina (or placental decidua) is 
merely that part of the uterine mucous membrane on which the 
ovum rests, and which, eventually, is covered by the placenta. 
When first formed, the decidua vera is a hollow, triangular 
sac, having three openings into it, being those of the Fallopian 
tubes and os uteri. It continues to develop, by hypertrophy, 
up to the third month, and then, owing to pressure, atrophy 
begins; the blood-vessels disappear, a fatty degeneration sets 
in, but the structure is not completely altered till gestation 
ends. The process is continued until it becomes thin and trans- 
parent. When fully developed, 
it presents, under a lens, char- 
acters which clearly establish 
its identity as hypertrophied 
uterine mucous membrane. 

The formation of the de- 
cidua reflexa is an interesting 
study. As elsewhere remark- 
ed, the ovum, on reaching 
the uterine cavity, finds the 
mucous membrane in a hy- 
pertrophied and convoluted 
state, so that the cavity of 
the organ is well nigh obliter- 
ated. It therefore forms easy 
attachment in a fold near the 
point of entrance, and the rapidly formed villi of the zona 
pellucida serve to retain it. The mucous membrane at the base 
of the ovum begins to sprout about it, and extends, until, after 
a time, the ovum is completely inclosed. Up to the third 
month, it should be remembered, the decidua vera and decidua 
reflexa are not in contact throughout, since this fact has an 
important bearing on the question of superfoetation. By the 
close of pregnancy the decidua reflexa, like the decidua vera, 
becomes greatly altered in appearance, and from a similar cause. 
It is then very like the decidua vera, with which it blends, and 
from which careful dissection only is able to separate it. 

The Placenta. — The villi of the chorion are sent down 
into the tissues of the decidua, whence is derived the nutri- 
ment so necessary to proper development of the ovum. After 
the vascular relation between the embryo and permanent 




Fig. 58. — Flap of Decidua Reflexa 
turned down, disclosing Ovum. 



Development of the Ovum. 



71 



chorion have been formed, the area of nutritive supply is 
greatly diminished by atrophy of the villi of the chorion over 
about two-thirds of its surface, and the thinning, as well, of the 
decidua reflexa, and obliteration of its vessels. Pari passu with 
these changes, the whole process of embryonic supply and waste 
becomes concentrated at the decidua serotina. The villi of the 
chorion at this point become arranged in tufts, sixteen to twenty 
in number, the villi themselves multiply , and a thick, soft, spongy 
mass results, which constitutes the foetal portion of the pla- 
centa. Within the trans- 
parent walls of the villi 
the contained vessels 
may be seen under the 
microscope, distended 
with blood, and present- 
ing an appearance some- 
what resembling that of 
a loop of small intestine. 
These capillaries are the 
terminal ramifications of 
the umbilical arteries 
and vein, with terminal 
loops contained in the 
digitations of the villi. 
From the accompanying 
cut it will be seen that 
each arterial twig is ac- 
companied by a corre- 
sponding venous branch, 
the two uniting to form 
the terminal arch or loop. By this means the blood of the 
foetus is brought very near the blood of the mother, but does 
not come into actual contact with it. This fact is verified by 
utter inability to force any fluid into the material circulation 
by the most carefully conducted injections through the foetal 
vessels. 

The existence of lymphatics, or nerves, in the placenta, has 
never been demonstrated. 

The spaces between the villi of the placenta, which have been 
demonstrated to be sinuses in which circulates material blood, 
extend through the whole thickness of the organ, closely 
embracing all the ramifications of the foetal tufts. The essen- 




Fig. 59. — Placental Villus, magnified. 



72 



Pregnancy. 




Fig. 60.— Foetal surface of the Placenta. 




Fig, 61. — Uterine surface of the Placenta. 



Development of the Ovum. 



73 



tial composition of the placenta when fully developed is noth- 
ing but blood-vessels. All the tissues which it originally 
contained have disappeared, save the blood-vessels of the 
foetus, associated with and adherent to the larger blood-vessels 
of the mother. 

General Description.— The placenta, upon examination as 
a whole, is found to be a soft, spongy mass, of nearly circular 
form. It measures about seven and a half inches in diameter, 
about an inch in thickness at the insertion of the unbilical 
cord, and has an average weight of about sixteen ounces. Its 
foetal surface is smooth, and, through the amnion which covers 
it, can be seen the vessels radiating in every direction over the 




Figs. 62 and 63. — Specimens of Placentae Succenturiatae. (Auvard.) 

surface of the organ. The uterine face has a roughened, 
spongy feel, and is divided into a number of lobes, correspond- 
ing to the foetal tufts, or cotyledons, before described. The 
latter are penetrated by curled arteries from the uterus, which 
convey the maternal blood into the lacunar or sinuses between 
the foetal tufts. The blood returns to the uterus by the coro- 
nary vein on the margin of the placenta, and the sinuses in the 
septa between the cotyledons. 

Functions.— " The placenta," says Dalton, "must accord- 
ingly be regarded as an organ which performs, during intra- 
uterine life, offices similar to those of the lungs and the intes- 
tines after birth. It absorbs nourishment, renovates the 
blood, and discharges by exhalation various excrementitious 
matters which originate in the process of foetal nutrition." 



74 



Pregnancy. 



Abnormalities of form are often met. The organ is some- 
times divided into distinct parts; while, again, similar supple- 
mentary placentae, or placentae succenturiatee, may be found 
around the main mass. When this condition exists, one of the 
parts is liable to be left behind, exposing the woman to dan- 
gers of septic infection and secondary hemorrhage. The umbili- 
cal cord, instead of being attached to the center of the organ, 
may be at the margin, in which case it is termed battledore 
placenta. 

The term insertio valamentosa is applied when the umbilical 




IT AR.LAYER. 

Fig. 64. — Section of Uterus and Placenta in the fifth month. Ch. chorion. 
Am. amnion. V. villi. L. lacunae. S. serotina. Ar. areolar. V. small 
arteries. (Leopold.) 

vessels extend for some distance along the membranes before 
reaching the placenta. 

Changes Preparatory to Separation— At about the eighth 
month the giant cells of the serotina, until this time in con- 
tact with the veins, begin to penetrate the vessels, and by 
their presence constitute foci of coagulation. These, together 
with a varying amount of fatty and calcareous degeneration, 
prepare the placenta for easy separation in labor by the con- 
tracting uterus. 

The Umbilical Cord.— This is formed chiefly by elonga- 
tion of the pedicle of the allantois, and obliteration of its 
cavity. Thus constructed it consists of the following parts: 
the amniotic sheath (which entirely surrounds it, except at 



Development of the Ovtjm„ 75 

one point, where a small slit gives egress to the pedicle of the 
shrunken umbilical vesicle); the two umbilical arteries, and 
one vein ; the remains of the pedicle of the umbilical vesicle ; 
the remains of the pedicle of the allantois; and finally the 
gelatine of Wharton. It is usually about the thickness of 
the little finger, but varies greatly, its circumference depend- 
ing mainly on the quantity of Wharton's gelatine. Owing 
to the greater length of the right artery, the vessels in their 
spiral course commonly observe the direction from right to 
left, the vein forming an axis about which the arteries curl. 
The average length of the cord is twenty-two inches, but it 
has been observed as short as three inches, and as long as 
five or six feet. As a rule, it possesses considerable strength, 
as may be demonstrated by traction made upon it for the 
purpose of placental removal. Still, in some cases, slight 
traction will cause it to part. One extremity is firmly attached 
to the umbilicus, and the other to the placenta. No nerves 
or lymphatics are said to exist in its structure. 

The Liquok Amnil— The amniotic fluid is supposed to result 
mainly from the exudation of serum from a fine capillary net- 
work of blood-vessels developed just beneath the amnion, in 
that part of the chorion which covers the placenta. In the 
latter half of pregnancy this network of vessels disappears. 
The quantity varies greatly, and diminishes after the fifth 
month. When in excess of three pints, the condition is one of 
hydrops amnii. 



76 



Pregnancy. 



CHAPTER II. 

DEVELOPMENT OF THE EMBRYO AND FCETUS. 

An account of the development of the embryo and foetus 
belongs properly to physiology, and allusion to it here is 
designedly brief. The term embryo is properly applied to the 
product of conception up to the close of the* third month of 
utero-gestation, after which time the term foetus ought to be 
substituted. Embryology, save for the light which compara- 
tive physiology throws upon it, is, in the human, shrouded in 
much obscurity. The opportunities afforded for the examina- 








Fig. 65. — Ovum and Embryo. 



Fig. 66. — Ovum of seven 
weeks. (Natural size.) 



tion of bodies, dead in the early stages of pregnancy, are 
very limited, and it is probable that our acquaintance with the 
subject must continue to be made chiefly through study of the 
process in animals. 

In the First Month. — The embryo, in the first week of ges- 
tation, is a minute gelatinous and semi-transparent mass, of a 
grayish color, presenting to the unaided eye no definite traces 
of either head or extremities. The entire ovum measures but 
one-fourth of an inch, and the embryo one-twelfth ; but during 
the next week they double in dimensions. The amnion becomes 
fully developed. The allantois reaches the periphery of the 
ovum, but the vessels do not yet penetrate the villi. At the 
close of the month the ovum is about the size of a pigeon's 
egg, and weighs about forty grains. The embryo is about 
three-fourths of an inch in extreme length, and about one- 
third of an inch in direct measurement. The structures have 



Development of the Fcetcs. 77 

so little bulk that, when ruptured, they easily escape attention, 
in abortions, generally passing with a coagulum. 

Second Month.— At eight weeks the ovum is about the size 
of a hen's egg, and the well developed villi of the chorion are 
still imbedded in the decidua throughout. It weighs from 180 
to 300 grains. The embryo is about two-thirds of an inch in 
length from head to caudal curve; its independent circulatory 




Fig. 67. — Ovum at five months. 

system is forming; indications of the external generative organs 
are visible ; and ossification has begun in several parts of the 
body. 

Thied Month.— The embryo weighs from 300 to 400 grains, 
and measures from 2% to 3% inches in length. The forearm is 
well formed and the fingers are discernible. The umbilical cord 
is about 2% inches in length. The head is relatively large ; the 
neck separates it from the trunk, and the eyes are prominent. 



78 Pregnancy. 

The chorion has lost most of its villi, and the placenta is 
formed. Points of ossification are present in most of the bones. 
Thin membranous nails appear on the fingers and toes. Sex 
may be determined by presence or absence of a uterus. 

Fourth Month. — The foetus weighs five or six ounces, and is 
about five inches long. Its sex is more distinct. Movements 
are visible. The convolutions of the brain are beginning to 
form; ossification is extending; the placenta is increasing in 
size, and the cord is about twelve inches long. The head is 
one-fourth the length of the w T hole body. The sutures and 
fontanelles are widely separated. Hair begins to appear on 
the scalp. If born, the foetus may live three or four hours. 

Fifth Month. — Foetal w T eight has increased to ten ounces, 
and length to about nine inches. The head is still relatively 
large. Fine hair (lanugo) appears over the whole body. Foetal 
movements can be felt by the mother. If born, the foetus can 
live but a few hours ^ 

Sixth Month.— Weight about twenty-four ounces ; length 
about eleven inches. Fat is found in the subcutaneous cellular 
tissue. The testicles are still in the abdominal cavity. The 
clitoris is prominent. Hair is darker and more abundant. 
The membrana pupillaris exists, but the eyelids separate. If 
born at this time the foetus breathes freely, but life is retained 
only a few hours, with rare exceptions. 

Seventh Month.— Weight from three to four pounds ; length 
fourteen or fifteen inches. The skin is wrinkled, of red color, 
and covered with vernix caseosa. The testicles have descended 
into the scrotum. The pupillary membrane disappears. If 
younger than twenty -eight weeks it is not likely to live. 

Eighth Month. — Weight from four to five pounds ; length 
sixteen to eighteen inches. Development is now rather in thick- 
ness than in length. The nails are nearly perfect. The lanugo 
is disappearing from the face. The navel has gradually ap- 
proached the center of the body, until now it has nearly 
reached that median point. The cranial bones are easily mould- 
ed under pressure, a point to be remembered, as bearing on the 
question of induced labor in pelvic deformity. 

Ninth Month, or At Term. — At the end of pregnancy the 
foetus weighs an average of six and a half or seven pounds, 
and measures about twenty inches in length. If we were to 
take the weights of children as given by mothers and friends, 
this average would be greatly increased. Out of 3,000 children 



Development of the Fcetus. 79 

delivered under the care of Cazeaux, at different charities, but 
one reached ten pounds. Of 4,000 children delivered at La 
Maternite one only weighed twelve pounds. (Lachapelle.) The 
birth of one has recently been recorded whose weight was 
twenty-one pounds. Probably the largest foetus on record was 
that born in Ohio to Mrs. Captain Bates, the Nova Scotia 
giantess. Its weight is said to have been nearly twenty-four 
pounds. Children have been born at maturity, and lived, 
whose weight was only one pound. The average weight of 
mature males is greater than that of females. 

At birth the foetus is covered with vernix caseosa, a whitish, 
tenacious substance, composed of a mixture of surface epithe- 
lium, down, and the products of the sebaceous glands. During 
intra-uterine life it serves as a protection for the skin against 
the amniotic fluid. It can be thoroughly removed only by 
preceding the use of water with a free inunction. 

Circulation of the Blood in the Foetus.— The following is 
a brief, but yet explicit, resume of the foetal circulation : Blood 
is conveyed through the umbilical arteries, which are termina- 
tions or branches of the iliac arteries, to the placenta, where, 
within the villi of the chorion, the interchanges with the ma- 
ternal blood take place. After being thus renovated and 
recharged with oxygen, it collects within the umbilical vein, 
from innumerable branches, and passes back through the 
umbilical cord to the liver. The blood thus returned to the 
foetus is arterial, and that which passed through the umbilical 
arteries, venous ; but it is so in a modified sense only. After 
reaching the liver, on its return from the placenta, a part of it 
first circulates through the liver, and then passes out through 
the hepatic veins, while the rest goes through the ductus 
venosus into the inferior vena cava, and both of these streams, 
uniting in this vessel, continue on to the right auricle. The two 
columns of blood, that is, the blood passing into the vena cava 
from the hepatic vein, and from the ductus, join the stream 
which has been collected from the lower part of the body, and 
mix with it. In early foetal life the inferior vena cava opens 
at the septum of the auricles into both cavities, though the 
chief part of the blood enters the left, owing to the increased 
development of the Eustachian valve. Subsequently this valve 
becomes smaller, and by the increased development of the valve 
guarding the foramen ovale, the current is turned more and 
more into the right auricle. In this cavity the blood is partly 



80 



Pregnancy, 




Dtrcfus 
Anteniosvus, 



IntmaJWia 



FlG> 68.— Diagram of the Foetal Circulation. 



Development of the Foetus. 81 

mixed with that which enters from the superior vena cava, and 
a part of it descends into the right ventricle, whence it passes, 
in part, through the pulmonary artery, into the lung tissue. 
No proper pulmonary circulation having yet been established, 
only about half the blood contained in the right ventricle enters 
the pulmonary artery, whilst the other half enters the descend- 
ing aorta through the ductus arteriosus. The imperfectly 
developed pulmonary veins convey to the left auricle but a 
small quantity of blood, the chief supply being received from 
the right auricle through the foramen ovale, through which 
passes the main stream from the inferior vena cava. From the 
left auricle the blood, which is semi-arterial, descends into the 
left ventricle, and thence into the first division of the aorta. 
By virtue of this movement the head and upper extremities are 
supplied, through the carotid and subclavian arteries, with the 
blood which has been but little deteriorated in quality, and 
escape the more venous current from the right ventricle 
through the ductus arteriosus. 

At the birth of the fcetus there occurs a profound revolution 
in the circulation. Air now enters and expands the lungs, and, 
as a result, blood begins to pass freely into the pulmonary cir- 
culation. The blood received into the right ventricle is now 
forced through the pulmonary system exclusively, the ductus 
arteriosus at once closing. After passing through thelungs and 
being oxygenated, the blood flows in greatly increased quantity 
into the left auricle. It is presumed that in the latter cavity 
the blood pressure is considerably increased by cessation of the 
placental circulation, while, through moderation of relative 
supply, the pressure on the right auricle is diminished, by means 
of which changes the valve of the foramen ovale is enabled to 
close. As a result of these modifications, more especially in con- 
sequence of closure of the ductus arteriosus, the arterial press- 
ure in the descending aorta is greatly diminished, and were the 
placenta left unseparated from the child, the long placental 
circulation could not be maintained. The blood still left in 
the^cord soon coagulates, and circulation therein is effectually 
arrested. The ductus venosus also contracts on complete es- 
tablishment of the pulmonary circulation. The foramen ovale 
sometimes remains open for a short time; but after its closure, 
owing to the peculiar construction of its valve, and the greater 
blood pressure in the left auricle, there is no intercommunica- 
tion between the contents of the two cavities. 
(6) 



82 



Pregnancy. 



The Cranium. — The general anatomy of the foetal head is of 
much greater value to the obstetrician or student of midwifery 
than that of any other part of the body. Apart from its dimen- 
sions, the chief anatomical peculiarity of interest is that of the 
cephalic bones, and more especially of the calvarium. These 
bones are not firmly ossified at their contiguous margins in the 
foetus, but are loosely joined by membrane or cartilage, forming 
above, by their united margins, sutures, or commissures, and 
fontanelles. This arrangement permits the bones under forcible 
pressure to overlap, and the head thus to be moulded to cor- 
respond to the size and shape of the channel through which it 





Fig. 69.— The Vertex. 



Fig. 70. — Posterior view 
of the Cranium. 



has to pass. Since this change in form of the head affects only 
the vault of the cranium, the more delicate organs in the base 
of the brain are protected by unyielding osseous structures; 

An acquaintance with the characters of the foetal cranium 
is of the greatest service in furnishing the data from which to 
calculate the position occupied by the part as it presents in 
labor. 

The Sutures and Fontanelles .—The sagittal suture ex- 
tends along the vertex, between the anterior and posterior 
fontanelles, and is formed by the junction of the two parietal 
bones. Running forward in the same line, anteriorly from. the 
anterior fontanelle, is a short seam known as the frontal 
suture. The coronal suture is formed by junction of the edges 
of the two parietal bones and the frontal, and hence extends 
over the head in a la/teral direction, constituting the anterior 
transverse suture of the vault of the cranium. The lambdoidal 
suture is the line of demarcation between the occipital and 



Development of the Fcettjs. 



83 



two parietal bones, extending transversely across the head, 
and forming a figure which resembles the Greek letter A, from 
which its name is derived. In the other commissures of the 
foetal cranium we have no special obstetric interest. 

Ossification of the cranial bones at birth is incomplete, 
especially at the margins which are thus approximated, and 
as the bones have only membranous, or, at the most, cartila- 
ginous, union, moulding of the head through overlapping of 
the bones under the necessary compression is generally accom- 
plished with facility by the natural efforts, and thereby great 
mechanical advantage is gained. 

The corners, or angles, of the bones, as thus approximated, 
are obtuse, especially at the junction of the coronal, sagittal 
and frontal sutures, through deficiency of osseous structure, 
and hence there are gaps formed 
anteriorly and posteriorly, which 
are termed fontanelles. The 
largest of these is the anterior * 
fontanelle, or bregma, it being 
formed by the concurrence of 
four seams, namely, the sagittal, 
the frontal, and the two branches 
of coronal, giving to the opening 
a lozenge shape. The larger part 
of the gap is in front of the Fig. 71.— Lateral view of Head, 
direct line of the coronal suture, with indicated Diameters. 

and is sometimes continued some distance into the frontal 
bone in the line of the frontal suture. The posterior fontanelle 
is very much smaller, and, in general, is hardly entitled to the 
designation, since it would be scarcely possible to observe any 
pulsation there. Its shape is characteristic, and is rendered 
still more distinct during labor by the depression of the 
occiput, whereby the limbs of the A are made prominent. As 
will be noticed further on, the occiput, in the greater portion of 
cases, is turned towards the pubis, and hence the posterior 
fontanelle is the one more easily felt by the finger in making 
an examination during labor. Too much emphasis cannot 
be put on its characteristics, namely, its A shape, and the 
concurrence of only three commissures (the two branches of 
the lambdoidal and the sagittal). The anterior fontanelle 
is lozenge-shaped, and has four sutures concurrent, as stated. 
The angle is much more obtuse; but what most markedly 




84 Pregnancy. 

distinguishes it is the existence of the notch, more or less dis- 
tinct, in the frontal bone. These characters will not at first 
be readily recognized by the student, but repeated examina- 
tions will render them familiar. 

Diameters of Fwtal Cranium. — Familiarity with the rela- 
tive diameters of the foetal head is essential to an intelligent 
practice of midwifery. Those of most importance are: 1. The 
occipito-mental, measurement being taken from the occipital 
protuberance to the point of the chin, the average giving five 
and one-half inches. 2. The occipitofrontal, from the occiput 
to the center of the forehead, on a line with the frontal 
eminences, four and three-quarters inches. 3. The cervico- 
bregmatic, one pole being at the foramen magnum, and the 
other at the posterior margin of the anterior fontanelle, about 
three and one-half inches. 4. The bi-parietal, the two poles of 
the diameter being the parietal eminences, three and three- 
quarters inches. 5. The bi-temporal, being the measurement 
through the ears, three and one-half inches. 6. The fronto- 
mental, from the apex of the forehead to the chin, three and 
one-half inches. 7. The sub-occipito-bregmatic, one pole being 
say half an inch below the occipital protuberance, and the 
other at the anterior fontanelle, three and one-half inches. 
8. The bi-malar, the poles being at the outer margins of the 
malar bones, three inches. Others might be added, but those 
given comprise most of the diameters concerned in the mechan- 
ism of labor. Putting these figures in tabular form, they are 
as follows : 

Inches. 

Occipito-mental 5% 

Occipitofrontal . . 4% 

Cervico-bregmatic %% 

Sub-occipito-bregmatic ...... %% 

Bi-parietal . 3% 

Bi-temporal 3% 

Fronto-mental 3% 

Bi-malar 3 

Without pausing now to dilate on the change of diameters 
which is effected by different presentations and positions, it 
ought to be added that these averages were taken from heads 
which traversed the parturient canal in occipito-anterior 
positions of vertex presentations. Dr. Barnes has shown by 
diagrams made from heads immediately after delivery, that, in 
difficult and protracted labor, the longer diameters may be in- 



Development of thu Foetus. 



85 



creased more than an inch, as the result of lateral compression, 
by which the bi-parietal diameter is reduced to correspond with 
the bi-temporal. 

Heads of Male and Female Children— -There are some gen- 
eral considerations in relation to the size of the foetal head 
which must not be overlooked. On taking the average meas- 
urements of a large number of male heads, and comparing them 
with those of an equal number of female heads, it becomes evi- 
dent that the former exceed the 
latter. Sir James Simpson at- 
tributed to this fact the increased 
difficulties and dangers attendant 
on the birth of male children. 
This influence he believed to be so 
marked, that he made a careful 
estimate of the mothers and chil- 
dren lost in Great Britain during 
three years, as the result of slightly 
increased cranial development in 
males, at about 46.000 infants, and 
between 3,000 and 4,000 mothers. 

Attitude, Presentation and 
Position of the Foetus. — From 
the earliest period in pregnancy the 
foetus in the uterus conforms itself 
to the shape of the organ in the 
cavity of which it is placed. Its 
adaptation to a bent and flexed 
attitude is clearly disclosed early in 
embryonic life. While yet it floats 
freely in the liquor amnii, and is 
not at all pressed by the uterine 
Avails, the correspondence of the embryonic with the foetal ovoid 
is worthy of notice. The flexed attitude becomes more marked 
as pregnancy advances, and at the close of gestation the foetus 
is found with the spinal column bent forwards, the chin on the 
chest, the arms flexed at the elbows and the forearms laid on 
the breast. The thighs are bent on the abdomen, the feet 
extended so as to come in contact with the legs, and the latter, 
like the forearms, often crossed. This attitude enables the foetus 
to occupy the minimum amount of space, and gives to it the 
form of an ovoid, with the smaller end represented by the head. 




Fig. 72.— Attitude of the Foetus 
in Utero. 



86 Pregnancy. 

Presentations and their Causes.— The position of the foetus 
with respect to the direction of its long axis, constitutes^ what 
is known as presentation. When the cephalic pole of the 
longitudinal diameter is dependent, itisa cephalic presentation. 
When the knees, feet or breech lie over the os uteri, the pelvic 
pole of the long diameter presents, and hence it is called a pelvic 
presentation. Finally, when neither pole of the long diameter 
is in advance, it is a transverse presentation. In more than nine 
mature cases out of ten the cephalic extremity forms the pre- 
sentation. Various theories have been advanced in explanation 
of the phenomenon, but notwithstanding the attention be- 
stowed on the subject, and the profound research to which it 
has given rise, the mystery remains only partially solved. It 
does not answer the claims of science to let the question rest 
merely on the plea of the suitability or desirability of such con- 
ditions for the facile consummation of the reproductive pro- 
cess. Manifestly, there is a cause, the influence of which is felt 
from an early period in foetal life, the ultimate effect of which 
is discovered in the wonderful adaptation of means to ends in 
the mechanism of labor. Hippocrates appears to have origi- 
nated the idea that, until the seventh month of gestation, 
the foetus occupies a sitting posture, with the vertex turned 
to the fundus uteri, where it is held by bands from the 
umbilicus, and that then, as a preparation for expulsion, a 
complete change of presentation is effected. The smaller per- 
centage of cephalic presentations in miscarriages probably 
suggested this notion. Aristotle referred the frequency of head 
presentations to the laws of gravity, which is a theory still 
tenaciously held by some. To test this gravity doctrine, 
Dubois experimented by suspending dead foetuses, of different 
ages, in a vessel filled with water, and found that not the head, 
but the back or shoulder, was the part which rested on the bot- 
tom. He accordingly denied the influence of gravity, and 
advanced the theory of instinctive or involuntary foetal move- 
ments to explain the phenomenon in question. Simpson, too, 
repudiated the theory, and substituted that of reflex foetal 
movements. Others have attributed the phenomenon to uter- 
ine contractions. Dr. Matthews Duncan has done more than 
any other recent observer to elucidate the subject. In numer- 
ous experiments made by him, in which foetuses recently dead 
were allowed to float in a bag filled with salt water, of a specific 
gravity corresponding closely to that of the liquor amnii, it was 



Development of the Fcetus. 87 

seen that the head lay lower than the breech, and that the right 
shoulder (from the increased weight of that side due to the sit- 
uation of the liver) looked downwards. This appeared clearly 
to demonstrate that the center of gravity lies nearer the cephalic 
than the pelvic extremity. " The position (presentation) of the 
foetus at the full time is," says Dr. Duncan, " in the great mass 
of cases, fixed and determined about the end of the seventh 
month of pregnancy. This arises from the fact that about that 
time the size and shape of the uterus become so nearly and 
closely adapted to the size and form of the fcetus, that it cannot 
change the position of its trunk in any material degree. After 
this time the position of the fcetus must be determined by gravi- 
tation, for it is impossible to conceive its reposing in any other. 
"All the knowledge we possess of the position (presentation) 
of the foetus, after it has entered the second half of pregnancy, 
leads us to believe that its head lies ordinarily lowest. Before 
the seventh month it is still capable of having its position in 
utero changed, by changes merely in the attitude of the mother, 
and probably it possesses the power of effecting temporary 
changes, at least, by its own unaided movements. But the 
foetus is generally in a state of repose, and not producing 
motions in its limbs or body. In this state of repose, in a fluid 
of nearly its own specific gravity, it is impossible to conceive of 
its maintaining any position but under the influence of gravity. 
Its position must at all times be mainly, if not entirely, caused 
and determined by statical circumstances. It is quite conceiv- 
able, that while still comparatively free in the uterus, it may, 
by virtue of its very easy mobility in the dense liquor amnii, 
change its position. If this occur at a time when its dimensions 
are beginning to approximate to those of the uterus, having 
overcome some resistance of the uterine walls by the force of its 
own muscular efforts, or otherwise — as by accidents to the 
mother— it may not gravitate back to its old and ordinary 
position, and thus a preternatural presentation may be pro- 
duced. The uterine walls are every where smooth and glabrous, 
and rounded; and the foetus lies in its cavity with its legs, its 
chief organs of locomotion, elevated, circumstances which ap- 
pear to render its maintenance of any position but that of 
gravitation a greater feat than ever was performed by a rope 
dancer. With all the advantages of its new circumstances, the 
child after birth cannot assume or maintain a new position : 



88 



Pregnancy. 



how much less could it be expected to do so in the uterus, and 
under circumstances so disadvantageous for the fulfillment of 
such a function ! Those authors who, with Dubois, strive to 
prove that the position of the foetus is determined by its own 
motions have first to prove that it could maintain any position 
whatever against gravity, without such constant efforts as 
voluntary muscles are incapable of, and of the actual presence 
of which no evidence can be furnished." 

The law of fcetal accommodation, formulated by Pajot, 
should be accredited with considerable influence in the determi- 
nation of presentation. "When one solid 
body is contained in another,''* says he, "and 
if the latter is alternately in a state of motion 
and of repose, and if the surfaces are rounded 
and smooth, the included body constantly 
tends to accommodate its shape and dimen- 
sions to the shape and capacity of the contain- 
ing body." 

Without entering further into a consider- 
ation of this question, it may be added that 
cephalic presentation of the foetus is not 
probably referable wholly to any one cause, 
but a combination of causes, in which gravi- 
tation, uterine contractions, and reflex move- 
ments, all have an influence. 
Position. — By this term we design to signify the relation of 
certain determinate points in the body of the foetus to the uter- 
ine walls. Care must be taken not to confound the two terms 
— presentation and position. To simplifj^ an understanding of 
the various positions, we shall regard the dorsal surface of the 
foetus as the cardinal feature from the direction of which to des- 
ignate positions. And still it will be observed, when this sub- 
ject is treated at length, that positions are often designated by 
the direction of the occiput in vertex presentation, and the chin 
in face presentation, as, for example, right occipitoanterior 
position, left mento-posterior position, and soon. Full consid- 
eration of this subject will be taken up in another chapter. 
Changes of position are frequent in pregnancy, and, we suppose, 
like presentations take place when not subjected to contrary 
influences, in a large measure through obedience to the law of 
gravity. This is not mere speculation, for close observation 




Fig. 73.— The foetal 
Ovoid. 



Development of the Fietus. 



89 



has substantiated its truth. When the woman is in the erect 

posture, the axis of the uterus is presumed to correspond closely 

with the axis of the plane of the superior strait, and hence forms 

with the horizon an angle of about thirty degrees. There is 

generally a little deviation to 

the right. It is also slightly 

twisted, so that its left lateral 

surface looks somewhat forwards. 

Therefore, when the woman is 

erect, the anterior uterine wall 

is not only inclined at the angle 

mentioned, but the left side drops 

a little lower than the right. 

"The deviation of the uterus 
during pregnancy," says Auvard, 
"designated by authors gener- 
ally under the name of lateral 
obliquity, is not due to a true 
inclination of the organ during 
gestation, but to an apparent 
inclination. 

"It is not. in fact, an inclination of the uterus towards the 
right side or towards the left side, which is the cause of this lat- 
eral obliquity, but a want of equality and of parallelism in the 
development of the two halves of the organ. 

" When there is a true inclination, it is secondary to this ap- 
parent inclination ; it is due to the fact that the uterus is drawn 
as a whole towards the side most developed." 




Fig. 74. — Situation and surround- 
ings of the Foetus in Utero. 



90 Pregnancy. 



CHAPTER III. 



CHANGES IN THE MATERNAL ORGANISM WROUGHT BY 
PREGNANCY. 

Following closely on the heels of impregnation, changes are 
begun in the maternal organism, a knowledge of which is 
essential to an intelligent view of the subject of utero-gesta- 
tion, and the skillful performance of obstetric duties. 

Uterine Changes. — As soon as impregnation takes place 
Nature sets herself at work to prepare a nidus for the nestling 
which is about to enter the uterine cavity. The first noticeable 
change is an increased determination of blood to the uterus, 
one of the effects being an augmented thickness and rugosity of 
the mucous lining. As the fecundated ovum enters from the 
tube it is arrested by one of these folds, and the uterine mucosa 
rapidly rises and envelops it. This movement is the initial 
phenomenon looking to the formation of those important 
structures, elsewhere described, which are to enclose the ovum 
and ultimately be discharged with it, namely, the deciduae. 
The textural changes are both numerous and great. The mus- 
cular fibers increase in length and somewhat in breadth, while 
new elements are also added. Connective tissue is correspond- 
ingly developed. The three layers of muscular fibers running in 
different directions, which cannot be demonstrated in the non- 
pregnant uterus, become more and more patent. The arteries 
assume a spiral course and increase both in number and size, 
while the veins dilate and become wide-meshed reticulated 
anastomoses. The latter vessels form valveless canals or 
sinuses of considerable size, which intercommunicate, coursing 
through the muscular tissues, especially in the vicinity of the 
placenta. The lymphatics become more numerous and form 
plexuses in various parts. The nerves are correspondingly 
developed, and ganglia are found on the inner surface of the 
organ. 

The volume of the uterus is augmented, development being 
almost wholly confined to the body and fundus. This increase 
in bulk is due in part to hypertrophy of the walls, but also to 
distension from development of the ovum. The muscular 
changes which have been mentioned constitute the most essen- 
tial elements in the production of augmented weight of the 



Changes in the Organism. 91 

organ. The walls themselves are not materially altered in 
thickness. Uterine growth may be said to begin with preg- 
nancy and continue to its close: and yet it can scarcely be 
regarded as uniformly progressive. At different periods of 
gestation increase in size seems to be arrested, and then, after 
brief intervals of rest, development may be unusually active. 

Levret's figures give us as the area of the virgin uterus 16 
square inches, and that of the pregnant uterus at term 339 
square inches. Krause says the uterine cavity is enlarged by 
pregnancy 519 times. Pajot says if some observers find the 
uterus at full term measuring 15.7 inches through its greatest 
diameter, others find it only 12 to 14 inches long, including 
fundus, body and cervix. Following are his average measure- 
ments. 

Vertical diameter 14.6 

Transverse diameter 10.2 

Antero-posterior diameter 9.5 

Circumference at the level of the Fallopian tubes 27 to 28 inches. 

Cazeaux gives the following as the usual dimensions of the 
uterus at the principal periods of pregnancy : 

Vertical Diameter, Transverse, Antero-posterior, 
Inches. Inches. Inches. 

Third month . . 2% 2% 2% 

Fourth month ... 3^ S% 3% 

Sixth month ... 8^ 6% 6% 

Ninth month . . . 12^-14)^ 9% 8-9^ 

Farre has furnished the following table of approximate 
uterine dimensions for the several calendar months of utero- 
gestation, which we regard as nearer correct : 

Length, Width, 

Inches. Inches. 

End of third month 4)^-5 4 

End of fourth month 5^-6 5 

End of fifth month 6-7 h% 

End of sixth month 8_9 gi/ 

End of seventh month . . . . . io 71^ 
End of eighth month ..... 11 8 

End of ninth month 12 9 

As the uterus increases in dimensions, its serous covering is 
put upon the stretch, and, with advance of pregnancy, the lay- 
ers of the broad ligament separate, until finally theFallopian 
tubes and ovaries lie in contact with the uterus. 

In early months, while yet the uterus is a pelvic organ, the 



92 



Pregnancy. 



increase is rather in breadth and thickness than in length, as 
will be seen from Cazeaux's figures, making the organ more 
spherical than in a non-pregnant state. After it leaves the 
pelvic cavity, development of the organ is more in a longi- 
tudinal direction, until it comes to assume an ovoid shape, 
with the narrower extremity below, at the cervix and os. 
In the fifth month, the uterus fills the hypogastrium, and, 
in the ninth month, its fundus reaches the epigastrium. 

Change in Sit- 
uation. — The first 
change is in a down- 
ward direction, as a 
result of which, from 
its close anatomical 
relations to the blad- 
der, and the connec- 
tion, in turn, of the 
bladder to the um- 
bilicus by means of 
the urachus, there is 
abdominal flattening 
and umbilical retrac- 
tion. It is only after 
the gravid organ 
rises, so that its bulk 
is above the pelvic 
brim, that abdominal 
increase is observ- 
able. This change in 
situation, which takes 
place at the close of 
the third or begin- 
ning of the fourth 
month, is usually a 
slow one, and, when 
completed, enables us to feel the form of the organ in the hypo- 
gastrium. 

A few days before the advent of labor there is a slight subsi- 
dence, or downward movement of the uterus, very marked in 
some women, but scarcely noticeable in others. This dropping 
of the fundus is caused chiefly by the extreme relaxation of the 
soft parts which precedes delivery, to distension of the lower 




Fig. 75. — Height of Cervix and Fundus Uteri at 
different weeks of pregnancy. (Schultze.) 



Changes in the Organism. 



93 



uterine segment, and to a slight abridgment of the uterine 
longitudinal diameter. 

The Inclination of its Longitudinal Axis.— The fully de- 
veloped gravid uterus lies mainly within the abdominal cavity, 
its cervix directed downwards and backwards, and its fundus 
upwards and forwards. There is also, in general, a slight lateral 
obliquity, the inclination most frequently being towards the 
right. Situated thus, its anterior surface rests against the ab- 
dominal parietes, its long axis nearly parallel with the axis of 
the plane of the pelvic brim, thereby forming with the horizon 
an angle of about thirty degrees. It assumes the vertical line 
only when the woman is in the semi-recumbent posture. From 
excessive relaxation of the abdominal parietes, a pendulous 
condition is sometimes induced. 

Changes of Cervical Posi- 
tion. — The situation of the 
cervix must obviously depend 
largely upon the situation and 
inclination of the uterine body. 
Hence, in the early weeks of 
pregnancy, the cervix is within 
easy reach of the finger. After 
the third month it is higher, and 
situated so far posteriorly as 
sometimes to place it almost 
beyond reach of the index and 
middle fingers. 

Changes in the Size and Texture of the Cervix Uteri — 
The cervix shares in the hypertrophy of the body and fundus of 
the uterus, but this change is generally completed by the 
fourth month. The increase in size is partly from an increased 
growth and new formation of tissue elements, but more espe- 
cially from the loosening of its structure and distension of its 
tissues from serous infiltration. The cervical vessels, under the 
stimulus of the process going on in the uterine cavity, are di- 
lated, and the result is hypersemia of the part, and consequent 
oedema. These conditions in turn occasion a physiological soft- 
ening of the tissues, first manifested in those parts where there 
is least resistance, that is, under the mucous membrane on the 
lips of the os externum, and from this point continued progress- 
ively upwards towards the os internum. The cervical follicles 
are active, and pour out their secretions, though the formation 




Fig. 76. — Cervix Uteri at close of 
the Fourth Month. 



94 



Pregnancy. 



of a " mucus plug," described by some authors, is questionable, 
The orifices of these follicles are liable to occlusion, in which 
case little sacs are formed, known as the ovules of Naboth. 

Most of the standard works on midwifery allude to a pro- 
gressive shortening of the cervix uteri which is supposed to take 
place in pregnancy. Stoltz, in 1826, questioned the truth of 
this theory, but, according to Dr. Duncan, he was preceded by 
Weitbrech in 1750. Various post-mortem examinations by 
others have clearly shown that, contrary to the older teach- 
ings, the cervix does not lose half its length by the sixth month, 
two-thirds of it by the seventh, and all of it by the middle of the 




Fig. 77. — Cervix Uteri at beginning 
of the Fifth Month. 



Fig. 78. — Cervix Uteri at close 
of the Eighth Month. 



eighth. To be sure, the part does not present the promi- 
nence which it once possessed, but the change is in the direction 
of softening and elevation, without coincident shortening 
or obliteration of the cervical canal by expansion of the 
internal os uteri. We have insisted on the truth of this 
for years, as the result of careful examinations, and we are 
convinced that, in the majority of cases, the internal os uteri 
does not yield till labor supervenes, or is near. According to 
Dr. Matthews Duncan, the change occurs during the latter half 
of the ninth month, but, even then, obliteration of the cervical 
canal appears to be due to the incipient uterine contractions 
which prepare the cervix for labor. "The length," says 
Duncan, "of the vaginal portion of the cervix, or the amount 



Changes in the Organism. 



95 



of projection into the vaginal cavity, greatly diminishes as the 
uterus rises into the cavity of the abdomen." 

This is a pretty constant phenomenon of pregnancy, and is 
probably one of the causes of the mistaken ideas formerly 
entertained regarding cervical shortening by supposed yielding 
of the internal os. On making an examination, the vaginal 
portion of the cervix is found not to be as prominent as usual, 
and, indeed, in some cases is even scarcely to be felt, and the 
inference has generally been that the cervical body has been 
annihilated. The opposite effect is produced by depression of 




Fig. 79.— Cervix of a Multipara who died in the Eighth Month of 
Pregnancy. (Duncan.) 

the uterus, as in the early weeks of pregnancy. This change 
led Boivin and Filugelli to regard the cervix as lengthened. 

It is probably true, however, that to actual measurement 
there is a certain amount of cervical shortening, which takes 
place during pregnancy, growing out of the physiological soft- 
ening which occurs ; but it is not a shortening consequent on 
relaxation of the internal os, and infringement upon the cervi- 
cal canal, as has been supposed. We insist that post-mortem, 
and careful vaginal examinations, have clearly shown that the 
internal os uteri does not expand until near the close of utero- 
gestation. 

Another factor in the production of apparent shortening is 



96 



Pregnancy. 



probably the bulging of the uterine wall anteriorly to the cer- 
vix, as an effect of downward pressure of the presenting head. 
This condition, while common, though by no means uniform, 
causes the os uteri to be directed backwards towards the 
sacrum, and gives rise at times, especially in late pregnancy, to 
considerable difficulty in reaching the part, and at the same 
time produces a marked shortening of the anterior lip of the os 
uteri. By pushing the head upwards, or by placing the woman 
on her knees and elbows, so that the head will recede, the cervix 
is made to resume its normal situation and feel. This bulging 
of the lower uterine segment and backward displacement of 

the os, has, at times, been 
mistaken for anteflexion of 
the uterus. 

As pregnancy advances, 
the os uteri becomes more 
and more patulous, but the 
degree of expansion differs 
in primigravidse from that 
in multigravidse. In the 
former, after the fourth or 
fifth month, it gets slightly 
patulous, but will not re- 
ceive the end of the finger 
till a much later period. 
Even at the eighth, or mid- 
dle of the ninth, month, the 
margin of the os is pretty 
closelv contracted. Thecav- 




FlG. 



. — Cervix Uteri beyond the 
Seventh Month. 



ity of the cervix is wide, and if the finger be pushed through 
the external os, it readily permeates the canal. 

In pluripara? the cervical changes are somewhat influenced 
by the experiences of former pregnancies and labor. The cervi- 
cal canal does not assume the spindle shape, but rather 
resembles a thimble. The os tincse is more widely expanded, so 
that at the seventh month the finger easily enters the cervical 
canal, and approaches the internal os. At the eighth month, 
the latter, as a rule, has begun slightly to yield, though, in one 
instance, it may remain closely shut till the close of gestation, 
and, in another, be so widely expanded as to admit two fingers. 
Lusk mentions the case of a multipara whom he had occasion 
to examine towards the end of gestation to determine the 



Changes in the Organism. 



97 



question of safety in making a railroad journey to a neighbor- 
ing city. He found the cervix soft, the head low, and the 
internal os dilated to the size of a dollar. Two weeks later, he 
was called to see her in the early stage of labor, and found that, 
under the influence of uterine contractions, the canal of the 
cervix had again closed. 

Vaginal and Vulvar Changes.— In the vagina, changes 
take place corresponding in some regards to those in the uterus. 
The muscular fibers hypertrophy ; the vessels of the venous 
plexuses increase in size, and impart a blue, or purple color, to 




Fig. 81.— Showing the appearance of the Areola. 

the vaginal walls. The mucous membrane becomes thickened 
and amplified, so that though the vaginal tube is drawn upon 
by ascent of the uterus, the anterior wall of the vagina occa- 
sionally protrudes from the vulva. 

There is also turgescence of the vulva, pouting of the labia, 
duskiness of the mucous surfaces, and abundant secretion of 
the follicles. 

Changes in the Mammae.— Characteristic changes take 
place in the breasts of such value in the diagnosis of pregnancy 
as to merit close attention. Tingling and slight sensitiveness 
are the first indications of change here. These symptoms are 
soon supplemented by an uncomfortable sense of tension, which 
(7) 



98 



Pregnancy. 



precedes the external evidences of enlargement. Increase in size 
does not often become noticeable until the fourth month, 
though from an early period in pregnancy there is a painful sen- 
sation of fullness. The veins enlarge and become unusually 
distinct as they course beneath the skin, and as distension 
finally becomes excessive, the cutis yields in places, presenting 
reddish or white lines like those found on the abdomen. 

The nipples become turgid, prominent, sensitive, and, on 
slight stimulation, erect; but the most characteristic changes 




Fig. 82. — Lateral view at Sixth 
Month. 



Fig. 83. — Lateral view at Ninth 
Month. 



take place in the. areola. Often as early as the second month 
the surface of this part is soft, (edematous, and slightly ele- 
vated. The sebaceous follicles enlarge, and after a. time moisten 
the areola with their secretions. About the middle of preg- 
nancy, discoloration, arising from a deposit of pigment, is 
noticeable. Ifc is more marked in women of dark complexion, 
and, from the fact that it is more or less permanent, the sign is 
of value mainly in pri mi gravidas. Colostrum can usually beex- 
pressed from the nipples as early as the tenth or twelfth week. 
In the latter months of pregnancy, about the border of the 
areola is observed a ring presenting a peculiar appearance, 



Changes in the Organism. 



99 



called the secondary areola of Montgomery. The character of 
it can be better understood from the illustration on page 97 
than from any written description. Briefly stated, it looks as 
though the color had there been discharged by a shower of 
drops. The appearance is due to the presence of enlarged seba- 
ceous follicles devoid of pigment. 

Changes in the Uterine Appendages.— The ovaries en- 
large and rise with the broad ligaments; the Fallopian tubes un- 
dergo hypertrophy and lose thecilia3 from their epithelium ; the 
folds of the broad ligaments separate and become hypertrophied, 
and the enlarged round ligaments, owing to greater uterine 
development posteriorly, are united 
to the uterus at the junction of the 
posterior four-fifths with the an- 
terior one-fifth of the lateral uterine 
surfaces. 

Abdominal Changes —As uter- 
ine development goes on, the 
abdominal walls are put upon the 
stretch, and, in women who are well 
nourished, are increased in thick- 
ness by the abundant formation of 
adipose tissue. The umbilical ap- 
pearances are altered from stage to 
stage. At first, from causes before 
explained, there is marked retrac- 
tion of the part. This becomes 
progressively less, until, at the 
seventh or eighth month, it begins to assume the exact coun- 
terpart of its former appearance, by becoming prominent, 
owing to the pressure exerted from within. Abdominal dis- 
tension also gives rise to the formation of reddish streaks, or 
striae, which, after delivery, become bleached, so as to resemble 
cicatrices. They are more abundant upon the sides of the 
abdomen, where they form sinuous lines, varying in length. 
They are due to an atrophic condition of the skin-layers, to 
partial obliteration of the lymph-spaces, and to condensation 
of the connective tissue elements, which, instead of forming 
rhomboid meshes, run parallel to one another. They are mere- 
ly the result of distension, and are not limited to pregnancy. 

Relation of the Uterus to Surrounding Parts.— Toward the 
close of gestation the uterus lies with the anterior surface 




Fig. 84. — Pendulous Abdomen. 



100 



Pregnancy. 



'■Mfy 



directly in contact with the abdominal walls, the intestines 
having been crowded upwards and backwards until they sur- 
round the uterus like an arch. Its lower anterior surface 
rests upon the posterior surface of the symphysis pubis, and 
the lower uterine segment dips, to a certain extent, iuto the 
pelvic cavity. The posterior uterine wall lies in contact with 
the spine, by which the fundus is slightly deflected to one side. 
Disturbance of Neighboring Organs from Pressure.— 
The pressure exerted by the gravid uterus creates functional 
disturbance in the neighboring pelvic organs. Pressure on the 
bladder, at its cervix and fundus, produces a desire for frequent 
micturition. The rectum and intestines often become inactive, 

and the resulting constipation is 
an annoying complication of the 
pregnant state. Pressure on the 
sacral nerves causes pains in the 
thighs and legs; also cramps and 
difficult locomotion. Traction on 
the uterine appendages causes pain 
in the hypogastric and inguinal 
regions. (Edema of the lower half 
of the body, and varicose condition 
of the veins of the legs, rectum and 
vulva, arise mainly from pressure, 
but partly from vascular fullness of 
the pelvic vessels, induced by preg- 
nancy. In the latter part of preg- 
nancy, pressure on the stomach is 
annoying. The renal circulation may likewise be impeded. 

Changes in the Blood. — Amongst the most important altera- 
tions in the female organism, brought about by the pregnant 
state, are the changes which occur in the circulating fluid. An 
attempt has been made to overthrow the common notion that, 
during pregnancy, the woman is nearly always in a condition 
analogous to plethora, and to prove the fallacy of referring to 
this state of the vascular system some of the many ills of which 
pregnant women complain, such as headache, palpitation, sing- 
ing in the ears, and shortness of breath ; but the attempt has 
not been altogether successful. With these ideas of pathology, 
the treatment formerly applied was not illogical when viewed 
from the standpoint of the dominant school, resort being had 
to active antiphlogistic medication, low diet, and frequently to 





Fig. 85.- 



W \ 



-Striae of Pregnancy. 
(Winckel.) 



Changes in the Organism. 101 

venesection. We are told that it was not uncommon for women 
to be bled six or eight times during the latter months of gesta- 
tion, and we have the record of cases wherein such depletion 
was practiced as a matter of routine every two weeks, and 
sometimes much oftener. Such treatment is unquestionably 
wrong. 

It appears to have been conclusively demonstrated that 
there is an increase in the quantity of the circulating fluid, a 
little in excess of that demanded by the enormous vascular de- 
velopment. 

The increase is mainly of serum, but the number of white 
blood corpuscles, and the quantity of fibrin, are both aug- 
mented. On the other hand, there is a decrease in the number 
of red blood corpuscles, the quantity of albumen and iron of 
the blood. 

For the first six months fibrin diminishes in quantity, and 
for the remaining three it increases up to the point of 
hyperinosis. 

Following is an extract from tables showing the relative 
quantities of the before-mentioned constituents : 

Average. 
Red globules in pregnancy 111.8 
Albumen .... 66.1 
Fibrin .... 3.5 

Iron 6.75 

Average. 
Red globules in healthy man 141.1 
Albumen .... 69.4 
Fibrin .... 2.2 

Iron . • /• • 

Inasmuch as there is an increase in the total quantity of 
blood, the proper maintenance of 
the circulation demands an in- 
crease either in the frequency of the 
heart pulsations, or in the quantity 
of blood forced into the large ves- 
sels with each cardiac systole. FlG - 86. — Sphygmographic 

Observation of pregnant women Traci * g of the * ormal Pul ^ 

, .. . ,: ° „ . in a Pregnant Woman, 

teaches us that the first require- 
ment is not met: the action of the heart is not accelerated. 
The compensation, then, is in dilatation of the heart cavi- 



Maximum. 


Miuimum. 


127.1 


87.7 


68.8 


62.4 


4. 


2.5 


2% lbs. dried blood 


Maximum. 


Minimum 


152. 


131. 


73. 


62. 


3.5 


1.5 




H 



102 Pregnancy. 

ties and hypertrophy of the left ventricle, the auricles and 
right ventricle remaining unaffected. As a result of these 
changes, there is increased arterial tension, which imparts 
a peculiar fullness and strength to the pulse. According to 
Durosiez, the heart remains enlarged during lactation, but 
is rapidly diminished in size in women who do not suckle. In 
those who have borne many children the organ remains per- 
manently somewhat larger than in nulliparae. 

Miscellaneous Changes.— The nervous system generally 
becomes more sensitive. There are alterations in the intellec- 
tual functions, changes in disposition and character; morbid, 
capricious appetite, derangement of the senses of taste, smell 
and sight, and often dizziness, headache, neuralgia and syncope. 
Melancholia is sometimes met, which, in women predisposed 
thereto, occasionally ends in mania. The memory is weakened, 
especially when one pregnancy follows another in rapid succes- 
sion. On the contrary, the nervous system sometimes becomes 
calm and strong, and the woman experiences a peculiar sense of 
well-being. 

Respiration is rendered difficult from mechanical causes, es- 
pecially at a time just previous to the subsidence of the uterus 
hereinbefore alluded to, owing, as Dohrnhas shown, to diminu- 
tion in the vital capacity of the lungs. The thorax is increased 
in breadth and diminished in depth, while diaphragmatic action 
is greatly impeded. 

Gastric disturbances are common. Nausea and vomiting, 
which, from most frequent occurrence in the morning, have 
been called "morning sickness," are experienced by the majority 
of women during the early weeks. The author has found, how- 
ever, upon careful inquiry of women presenting themselves for 
confinement in Hahnemann hospital, that about forty per cent, 
of all cases entirely escape the annoying symptom. It gen- 
erally begins at about the sixth week of pregnancy, and con- 
tinues for from six days to six or seven weeks. In other cases 
it forms a complication of later gestation. The appetite is 
capricious, the longings being in some cases for even disgusting 
articles of food. Increased flow of saliva is often an accompa- 
niment. The bowels are sometimes loose, but constipation is 
more common. 

In view of the tumult of incipient changes going on, we can- 
not wonder that the health of women is somewhat impaired 
during the first three months of pregnancy After that time, 



Changes in the Organism. 103 

however, there is generally an improvement. The appetite 
returns, digestion becomes more active, and assimilation re- 
cruits the strength, and increases the weight. Gassner estimates 
the total increase at about one-thirteenth the entire weight of 
the body. 

Besides the pigmentation of the areola about the nipple, 
there is discoloration of the linea alba of the abdomen, and at 
times macula? appear on different parts of the body, particu- 
larly the face, but, as a rule, they disappear after delivery. 

Certain changes in the urine have, by some, been considered 
pathognomonic of pregnancy. These consist in the formation 
of a deposit when the urine is allowed to stand for a considera- 
ble time, which has been called kieste'in. It is observed after 
the second month of pregnancy, and up to the seventh or 
eighth. From the fact that a precisely similar substance is 
sometimes found in the urine of women who are not pregnant, 
especially if anaemic, and even in the urine of men, it cannot be 
regarded as a change peculiar to gestation. 

The Permanent Changes. — The uterus after delivery does 
not resume its nulliparous shape and size, but retains vestiges 
of the condition through which it has passed. The weight of the 
organ is increased to about an ounce and a half; the fundus 
and body are rounded externally ; the cavity of the body loses 
its triangular shape, and becomes much larger relatively to the 
cervix, while the os internum is left somewhat agape. The 
mucous folds of the cervix are in great measure obliterated, or, 
at least, are rendered indistinct, and the os internum is patent. 
Abdominal distension leaves indelible marks in the shape of 
the striae mentioned, which, from a reddish or brown color, 
become silvery -white like cicatrices. The pigmentation of the 
linea alba is never wholly removed. The breasts give evidence 
of former pregnancy in the existence of the silvery lines alluded 
to, and the discoloration of the areola, which has, in a measure, 
remained. In addition to these changes there are doubtless 
many which mark a difference between women who have borne 
children, and those who have not, but further evidence is in the 
main, referable to parturient effects. 



104 Pregnancy. 



CHAPTER IV. 

THE DIAGNOSIS OF PREGNANCY. 

Owing; to the obscurity and indeterminate character of early 
symptoms, and the weighty contingencies which hang upon 
the expressed conviction derived from examination, the diag- 
nosis of pregnancy is one of the most trying duties which the 
physician is called to perform. It is further intensified by the 
notion, so prevalent among people, that the signs of pregnancy, 
from the first, are, or should be, to the trained and skillful ob- 
server, clearly legible. 

In most cases wherein this interesting condition is suspected 
to exist, the woman is within marital bonds, and diagnosis is 
sought more from the promptings of curiosity than any other 
consideration. Such women, as a rule, are easily pacified with 
an equivocal answer. In other cases there is an entirely differ- 
ent posture of affairs, and diagnosis is requested, not out of 
idle curiosity, or to satisfy a momentary whim, but from the 
pressure of dire forebodings. The woman is not under the safe 
protection of marriage vows, and, urged on by her fast 
augmenting fears, or stimulated by an impugning conscience, 
she seeks positive knowledge. Again : the physician is consulted, 
not by the woman herself, but by her friends. Parents, per- 
haps, with or without heart-sickening suspicions of their 
daughter's unchastity, desire an explanation of the objective 
and subjective symptoms which have come to their knowledge. 
In many such cases, so much depends upon the diagnosis ren- 
dered, that an error will not be pardoned. The symptoms may 
be ambiguous, and a most careful investigation may not elicit 
conclusive evidence, but, by the conviction expressed, the physi- 
cian has generally to abide. No plea of having done as well as 
circumstances allowed, will atone for a mistaken opinion. A 
confession of error will not bind up a broken heart nor restore 
the lustre to a tarnished reputation. Furthermore, the physician 
is sometimes called upon for an opinion in cases under litigation, 
wherein alleged gravidity is an important factor, and final 
adjudication in fixing responsibility, or in directing the inher- 
itance of property, will be determined largely by the character 
of his expert testimony. 



Diagnosis of Pregnancy. 105 

Classification of the Signs.— The signs of pregnancy should 
always be classified as relative or presumptive, and positive or 
demonstrable signs. Upon one, or upon a number of the 
former, nothing more substantial, affirmatively, than proba- 
bilities, of various degrees of strength, can be predicated. An 
unequivocal affirmative diagnosis ought never to be given. The 
presumptive evidence may be so strong in certain instances as 
to leave few and feeble possibilities of error, and yet experience 
teaches the fallacy of drawing absolute conclusions from such 
data. There are four signs which may be regarded as positive, 
namely, foetal movements, ballottement, the sounds of the foetal 
heart and recurrent uterine contractions. By some teachers, 
however, the third alone is looked upon as unconditionally posi- 
tive, and this is what we formerly taught. 

Subjective Symptoms. — In the diagnosis of pregnancy, 
subjective symptoms should receive due consideration, but 
objective symptoms must constitute our main reliance. Women 
are too prone to draw their conclusions from intuitions and 
mental impressions, and as a result we sometimes have gra- 
viditas nervosa, disconnected, perhaps, with even the most 
common and essential physical indications of pregnancy. 

History of the Case. — Items of importance may be gath- 
ered from a recital of the history of the case, which should 
include an account of the mode of development, and the order 
in which the various observable and sensible signs were mani- 
fested. 

The Menstrual Flow ought to be carefully inquired after. 
There may have been a regular return of it throughout the 
supposed pregnancy; or there may have been complete sup- 
pression. Should the former condition prevail, it will justly 
arouse suspicion. In that case, ascertain wherein thecatamenia 
deviate from a normal standard. If menstruation has ceased, 
learn the circumstances under which it disappeared, and the 
peculiarities, if any, which characterized the last two or three 
" periods." 

Pregnancy in Women who Do Not Menstruate.— Cases are 
on record wherein young women have conceived before the 
menstrual function had been established ; while again, during 
lactation and suspension of menstruation, impregnation often 
occurs. 

Menstruation During" Pregnancy. — It is not very uncommon 
for a woman to menstruate once, twice or thrice after impreg- 



106 Pregnancy. 

nation, and cases are recorded wherein the catamenia returned 
with regularity throughout the full term. 

Durosiez observed that menstruation is more likely to per- 
sist in women affected with mitral stenosis. The flow in these 
anomalous cases differs from the normal in either quantity or 
quality, and is not often regular in its appearance. The source 
of the blood is probably the cervical canal, though in the early 
weeks it may come from the uterine cavity. 

"Morning Sickness "—a sign of some value— is largely sub- 
jective, and concerning it strict inquiry should be made. When 
was it first felt? At what times, and under what circum- 
stances, was it most troublesome? How long did it last? 

When quickening is alleged to have taken place, try to fix 
the date, and the precise sensations experienced. 

Unreliability of Subjective Symptoms.— With regard to 
information thus elicited from women, it should be observed 
that, while it affords valuable data to be used in constructing 
a diagnosis, it is liable to be wholly fallacious. The menstrual 
function may or may not be suppressed, and she may or may 
not have experienced morning sickness and foetal quickening. 
Facts are extremely liable to be misconstrued or misrepre- 
sented through either the woman's untruthfulness or mistaken 
convictions. 

Objective Symptoms.— For our diagnosis we must depend, 
then, almost wholly on objective symptoms. The same com- 
mon means of investigation are available here as in other cases 
where physical examination is required. They are, inspection, 
palpation (including "the touch"), percussion, and ausculta- 
tion, the relative value of which, and the methods of most 
effective use, will be briefly considered. 

Inspection. — Inspection will aid very materially, in perplexing 
cases, in carrying the inquirer to a correct conclusion. The ab- 
dominal contour of a woman who has reached the fifth month 
of gestation is quite diagnostic, even when purposely obscured 
to a certain degree by the apparel. The experienced observer 
is often able, by inspection of it, to differentiate between preg- 
nancy and simulating conditions. The precise outline of the 
gravid abdomen varies, but within limits which make all cases 
quite similar. As we take a lateral view of a pregnant woman, 
the abdominal enlargement is seen not to be equable, but its 
point of greatest projection is near its superior boundary. This 
peculiarity becomes more and more characteristic as pregnancy 



Diagnosis of Pregnancy. 107 

advances. The cause of this is obvious when we recollect the 
form of the uterus, and the direction of its long axis, which is 
at an angle of about 60 degrees with the horizon. 

This lateral view is of considerable value in the diagnosis of 
pregnancy. Mere circumferential measurements are of compara- 
tively little importance. 

A front view also of the abdominal tumor, taken when the 
woman is either standing or lying, reveals diagnostic charac- 
ters, more marked in the erect posture. First should be observed 
the absence of prominences and irregularities. It is not uncom- 
mon to find a difference between the two sides in point of full- 
ness, but the elevation is not confined to a circumscribed area. 
This is generally due to presence of the foetal trunk, as the 
writer has repeatedly demonstrated. Then, too, the tumor 
arising from pregnancy is narrower, and more prominent along 
the middle line, than is a pathological enlargement. 

Special abdominal appearances, aside from enlargement, 
should be remembered. During the first few weeks of utero- 
gestation, the abdomen, instead of being more prominent, is 
really retracted or flattened, and especially in the umbilical 
region. This phenomenon has already been explained, but we 
repeat: The uterus, from its uncommon weight, proceeding in 
part from actual increase in size, but largely from vascular en- 
largement, sinks in the pelvic cavity to an unnatural level, and 
in doing so drags upon the bladder, which, in turn, through 
the urachus, causes the retraction mentioned. 

Along a narrow line, extending from the umbilicus to the 
pubis, there is darkening, the shades varying from light brown 
to black. 

Foetal movements are often discernible. They are sometimes 
closely simulated by spasmodic muscular action, when, as a 
means of differentiation, palpation affords positive aid. 

Inspection of the breasts is a valuable means of diagnosis, 
by means of which the changes described in the preceding chap- 
ter will be observed. The appearance known as the "second- 
ary areola of Montgomery" should receive special attention. 

The purplish hue in the vaginal mucous membrane must be 
seen to be known, but, when once familiar to the eye, will afford 
considerable aid. 

The foregoing embraces an allusion to the principal appli- 
cations of this means of investigation. When intelligently 
employed, it furnishes valuable help to unravel perplexing cases. 



108 Pregnancy. 

Palpation. — If deprived of every sense but the tactile, the 
physician would still retain the means for making a satisfac- 
tory diagnosis in nearly all cases of suspected pregnancy. This 
mode of examination is in common use, and is highly 
regarded, yet there are many, even among those long in prac- 
tice, who, from lack of adequate comprehension of its possibili- 
ties, do not value it as highly as they ought. Abdominal palpa- 
tion alone is sufficient, in many ambiguous cases, effectually to 
dispel doubt. In early pregnancies it is not capable of such 
achievements, but when combined with the vaginal touch it 
becomes a most valuable aid. Later, however, the uterus, 
with its developing foetus, rises within easy reach of the hand, 
and admits of minute examination. The fundus uteri is always 
easily distinguishable and its height can be clearly determined. 

The uterine form, with broad, even front and lateral super- 
fices, is highly characteristic. If the examination be prolonged, 
the recurrent uterine contractions which are going on through- 
out the greater part of pregnancy will be felt under the hand ; 
and, during their prevalence, a pretty good outline of the 
gravid uterus can be distinguished. At the moment of con- 
traction, the surface of the uterus which comes under examina- 
tion, when not defaced by fibrous growths, conveys to the hand 
a smooth, regular feel. 

In the intervals between contractions, when there is no mus- 
cular resistance, it is possible, after the middle of pregnancy, to 
feel the foetal form through the uterine walls. At this period, 
and later, in many cases there is so great a relative redundancy 
of liquor amnii as to admit of remarkable foetal mobility. The 
head, if not presenting closely at the brim, as at this season it 
frequently is not, may easily be moved from one side of the 
abdomen to the other. In a modified degree this is also true of 
the extremities and trunk. The foetal movements, whether 
spontaneous or elicited, are felt by the palpating hand. If the 
abdominal walls are not too thick, palpation is thus capable 
of affording highly satisfactory evidence upon which to base 
diagnosis. 

If pregnancy be absent, then by deep pressure the abdominal 
walls in the hypogastric region can be depressed until the 
fingers touch the spine, in which case the physician may rest as- 
sured that there is no pregnancy which has advanced beyond 
the third or fourth month. If in making such an attempt, re- 
sistance is at once encountered, thorough exploration by deep 



Diagnosis of Pregnancy. 



109 



abdominal pressure and vaginal indigitation should be made to 
ascertain the nature of it. 

"The touch" is a highly efficacious mode of examination, 
and one which, in cases at all doubtful, ought never to be neg- 
lected. By means of it several important signs may be elicited. 
In the early weeks, the uterus, as before observed, lies lower in 
the pelvic cavity than during a non -pregnant state. This con- 
dition of itself would bo of no significance, and, at best, is but 
a feeble relative sign. After the third month, the uterus having 




Fig. 87. — Bimanual Examination in the Diagnosis of Pregnancy. (Martin.) 

risen so that its bulk lies above the pelvic brim, the cervix is 
elevated and turned backwards towards the rectum, thereby 
putting the roof of the anterior vaginal cul-de-sac on the stretch. 
This is a valuable relative sign when found as a concomitant of 
other presumptive symptoms. 

A few years ago Hegar described a sign of pregnancy, of ser- 
vice in the early weeks, which bids fair to become generally 
recognized as positive. It is of special value inasmuch as 
hitherto we have had nothing but relative signs upon which to 
base diagnosis until near the middle of gestation. 

In the early weeks, development of the uterus is confined 
pretty closely to the body and fundus, and expansion is 



110 Pregnancy. 

greater anteriorly and posteriorly than laterally. At the same 
time while softening; is just beginning in the lower part of the 
vaginal cervix, it is proceeding more rapidly in the supra- 
cervical uterine walls, so that there is soon a zone of uterine 
tissue at the uterine isthmus, which, to the touch, is softer and 
more boggy than the structures above and below. Then, too, 
as a result of these changes, it is found that the uterine wall 
there becomes more prominent, so that the cervix feels as 
though it were set on the inferior surface of a small sphere. 
This gives us, as among the first changes in form, that which 
causes the uterus to lose its pear shape, and the body of the 
organ to become more spherical. 

These changes can best be recognized through recto- 
abdominal, or recto-vaginal touch, while the uterus is de- 
pressed in the pelvis by means of abdominal pressure. 

The sign is available as early as the fifth week of preg- 
nancy. 

The marked changes in the cervix uteri which begin soon 
after impregnation and gradually progress to full consumma- 
tion, have elsewhere been described. At the close of the sixth 
or seventh week the lips of the os uteri communicate to the 
examining finger a slight sensation *of softness, at that time 
due, perhaps, in the main, to turgescence and tumefaction of 
the part, but doubtless attributable in a measure to physio- 
logical softening of the uterine neck, dependent on other 
causes. The process begins at the lowermost part and pro- 
gressively ascends. An examination made at the sixth month 
discloses softness to the extent of half its length, but not until 
near the close of gestation is the reduction complete. The 
gradually increasing expansion and dilatability of the os uteri 
which accompanies cervical softening, ought to be kept in mind 
during examination. 

The period at which the internal os uteri gives way, so 
that the cervical canal becomes part of the uterine cavity, 
admits of some diversity of opinion. It is the author's convic- 
tion (elsewhere expressed), based upon special observation of 
many cases, that it is not brought about until, or very near, 
the beginning of labor, and frequently not until pains have 
been for some time present. 

Allusion has been made to the diagnostic value of conjoint 
examination, i. e., abdominal palpation employed in connec- 
tion with the vaginal touch. By such manipulation it is possi- 



Diagnosis of Pregnancy. Ill 

ble to form an approximate estimate of the size of the uterus, 
and hence the probability or improbabilit} T of pregnancy. It 
should be indulged with due caution, as harshness is liable to 
produce most unwelcome results. 

There is a form of vaginal, or bimanual examination, the 
employment of which, at certain stages, will disclose a sign of 
pregnancy by us regarded as positive, namely, h allot t ement . 
It can be practiced by both hands upon the abdomen. To do 
so the woman must be placed on her side, one of the operator's 
hands resting above, and the other below the abdomen as she 
lies. By a sudden movement of the hand beneath the foetus, 
the latter may be displaced or tossed, and the impulse of its 
return communicated to the keen sense of the operator. 

Vaginal b all ott ement is performed by placing the woman 
on her back in a seini-recumbent posture, and then, with two 
fingers in the vagina, the uterine wall just anteriorly to the 
cervix is given a sudden push in the direction of the long uter- 
ine axis. This propels the foetus away from the lower uterine 
segment, but it soon sinks again in the liquor amnii, and the 
gentle tap of its contact with the uterine tissues may be felt. 
When clearly elicited, it is regarded as a positive sign of preg- 
nancy, but it requires skill and experience successfully to prac- 
tice the manoeuvre. It cannot be employed with satisfaction 
earlier than about the close of the fourth month, nor later 
than the seventh. 

Uterine fluctuation may sometimes be felt, according to Dr. 
Rosch, by conjoint manipulation— the hand on the abdomen, 
and two fingers in the vagina; but the delicacy of the sign ren- 
ders it unreliable for general use. It is recommended as a 
means of early diagnosis. 

Percussion.— This means of diagnosis fills but a small niche. 
The abdomen, in real gravidity, gives, on percussion over the 
uterus, sounds, mostly flat, always dull. Should resonance be 
obtained at the site of the enlargement, it may justly be 
regarded as almost conclusive evidence of non-pregnancy. 
It can be employed to confirm other indications, but as a 
means of positive diagnosis, it possesses no merit. 

Auscultation.— When Mayor, of Geneva, tentatively applied 
his ear to the abdomen of a pregnant woman, in the hope that 
he might hear foetal movements, and discovered the inaudibility 
of these, but heard the unmistakably clear sounds of the foetal 
heart, he brought within command a means of diagnosis at 



112 Pregnancy. 

ouce easy of application and unequivocal in indication . The 
foetal heart-beat is the positive sign of pregnancy. 

The sounds have been compared to those of a watch under a 
pillow, but an infinitely better idea of them may be obtained 
by listening to the heart of a new-born child. They were first 
heard by Mayor with the unaided ear, but we ought not to 
infer from this that immediate auscultation is preferable. The 
author has repeatedly demonstrated the superiority of the 
mediate mode. The double stethoscope gives best satisfaction. 
The instrument may be applied by firm or by light pressure, 
the latter being preferable. To properly do this it should be 
placed on the abdomen in such a way that it will rest evenly 
and lightly, and then the fingers entirely removed. Sounds can 
thus be heard which would otherwise be absolutely inaudible. 
This method of using the stethoscope requires considerable 
practice to obtain the best results. 

The area of audibility depends mainly on the position and 
presentation of the foetus. The sounds are conveyed to the ear 
with the greatest facility by solid tissues or substances ; hence 
they a*re most distinct when the trunk of the foetus, at a point 
near the heart, comes in contact with the uterine walls, and the 
uterine walls are in turn brought firmly against the abdominal 
parietes. A dorso-anterior position of the foetus is most favor- 
able for transmitting the impulse. The area of audibility varies 
considerably in extent. In one case the sounds can be heard 
over nearly the whole abdomen, while in another they are cir- 
cumscribed to a small space. When audible over an extensive 
area, there is always a point where the summum of intensity is 
reached. Since the left dorso-anterior position of vertex pre- 
sentation is most frequent, the sounds of the foetal heart are 
oftener heard on the left side below T the umbilicus. When the 
child is in the fourth position, the sounds are also on the left 
side. In second and third positions they are on the right side. 
In cephalic presentation the area of audibility is lower than in 
pelvic presentation. 

The rapidity of pulsation varies greatly, the average being 
about 135 beats per minute. 

There is want of unanimity among observers regarding the 
period in pregnancy at which the foetal heart is first audible. 
Practice will enable one listener to detect it at an earlier stage 
than another of less experience. De Paul says that he has 
heard it at the eleventh week. Naegle could not distinguish 



Diagnosis of Pregnancy. 113 

it before the eighteenth week, and his experience in this regard 
corresponds to that of the average skilled practitioner. 

What was formerly termed the "placental souffle," and 
regarded as a certain sign of pregnancy, is now more appropri- 
ately known as the uterine, or abdominal, souffle. This bruit, 
instead of proceeding from the utero-placental circulation, and 
marking the placental site, is probably occasioned by the 
uterine and abdominal circulation, the vessels of which in 
places are subject to pressure, and accordingly emit a blowing 
or purring sound. Large abdominal tumors, disconnected 
with pregnancy, also give rise to the same, or a similar, bruit. 
It may be modified, or entirely arrested, by the pressure of the 
stethoscope. As an indication of pregnancy, it doubtless pos- 
sesses some value, but it must not be admitted as a certain 
sign, and under no circumstances is it to be regarded as proof 
of foetal life. 

It is now well understood that, by auscultation of the ab- 
domen of a pregnant woman advanced beyond the fourth 
month, we may hear the pulsations of the foetal heart, the 
bruit de souffle, and occasionally foetal movements and the 
funic souffle. The first named is a positive sign of preg- 
nancy; the second is of little value save when it is certain 
that the woman has no other disease which can possibly give 
rise to it; while the third and fourth are, on one hand, so rarely 
audible, and, on the other, so ambiguous as to be of little real 
worth. 

The summary of the signs of pregnancy, which appears on 
page 114, may prove serviceable. 

Differential Diagnosis.— The subject of the diagnosis of 
pregnancy would be far from complete without a few observa- 
tions on differential diagnosis. 

It would be impossible to mention, in a short chapter, all 
those various conditions which are liable to be mistaken for 
pregnancy. 

When there is an enlarged abdomen which raises a suspicion 
of pregnancy, combined internal and external examination is 
highly important. Upon employing it, a tumor of some sort 
may be discovered, but, if extra-uterine, by careful manipula- 
tion of the cervix the uterus can generally be made out as a 
distinct and free organ, with walls which are not greatlr dis- 
tended. To pass the uterine sound is rarely necessary, except 
to render assurance doubly sure. If serious doubts are felt, it 

(8) 



114 



Pregnancy. 



3 8 

°& 

I CO 
<D 

32 

d s > 

73 cc ffi 



o°fld 

03 03 
rd 



^§03 

2 ' •> S 3 S o3 

lis 

"p Pi 
CbSd cp« a> 
s .5 d § PI O 

CO +J +J rO +J CO 



~ S P.J 



_o3 +h jt3 

Jd P do" d *H jJ 

^ Od oS O-g 

.•§ S 3 S « fl 

* 111 II 



H O CO 

•Ills 

CO ,— |J3, 

§ „£* 

.2 8 P 



■£ i > 

a f~ "^ cp 



fen* R 



M 2^2 

TD'd cp P 

P— < d 03 

=2 c 



rt =s - 

II 

I « 

2 r* OP 

I- IS 



d 

£ bo 



id 03 
r -1 co *P 



33 



3 * 

.§ fl 
s~d £3 

Ppl.2 P. 

P^cp 

P"k S.T! bo 

co co -P O <*> 
P<o3 O^V, 

0.61)^ 



S2df n 

cfp 
f^cw cp^ 

3°2o 

Illll 

3.02 > ,« 

d ^2^ 
■^ p _g p $ 

■§'£ p_;£ 

IK X^J ^ 03 



s s3 



^ a 

p§3 

33— E=h' 

o I'd 

o P op 

2° o 

P 3 P 



£ 2 r 



■ "C.SP 

'S3 

P tp.-S o 

sis 

>• > O 
co . > oS 

>3o^^ 

P <U P.c3 



= = i 

ii 



^2 

Mp° 
3g.^ 

.22 3 



S 33 

si 





5 


p 




^> 






5 


:p 

CO 








3 




5J 


CO 

p 


: 


05 


-d 




p 




CO 


^ 

&H 


P 
z 


V. 






= 






23 

PS oi 



P S 

CO A 



p p 

O.P 
P P 



3^ 



HI 

III 



"3'23 

2 Sbo3 

3 Jh m 

ai 

P cp 

" p 



03 P 

a -a 

P'S'S'S 

.2Ep3 

CO m <P <P 

O o ^ S 
0.2 c3 co 



^ 


3 

a 


C 


p 


p 


7i 

3 


bfi 






c 




oj 


aj 


i. 
^ 


3 


c 


a 


r - 


- 


c3 


- 


c 


~ 



o 

o3 ^3 _ _- g 

.'O'O CP'C CK'd^ 

iS b'n^ P< t 1 O £ rt w 



cp cp 

S3 



w P 
bo 

1? 






^9 



T3 bc M - 

3-3 « 

oj a CP 

i 8.3* 

2 ^6 



■Sip 



-iP 



3.2 cf .-S 



5,5Mgg 



d *** ^ 

cp & d a 5n ■ 
p° >^ 



bD t) +j cp 
P P ^ 03 

Sl 1.1 "3 
d bpP'Ot: 



^ CO 

CO CO 

a cj 

co a 
co 55 

O) " J 

Q, CO 

r^d ^ 

.3 "" '3 

P CP P 
Pd CX 

2cp2 

3 pnpl 



slpg 

co^ £.2 

£*?^ 
P..3 w 

oj -3 >> 

81 f S 

^''O+a'cp 

d cc P § . 
O o3 P'J2 bo 



d 

° p 
33 



p^ 



v 



iP cp 



+J o 



•P-d" 

B3 
^3 



-P5 



C/J- 



£d 

bjo§ 

£3 



p P 

2| 



Diagnosis of Pregnancy. 115 

would be an unjustifiable act. The feel of the lower uterine 
segment, in connection with other signs, is diagnostic. From 
the second to the fourth month the gravid uterus is peculiarly 
soft, Avhile if tumors are present it is harder. In hsematometra 
it is firm, but elastic, and may even give slight fluctuation. 
In chronic inflammation, the uterus is sometimes rather soft, 
but usually it is much harder than in pregnancy. Then, too, 
if inflammation exists, other symtoms, such as tenderness 
and pain, will strengthen diagnosis. Diagnosis in some cases 
may still be uncertain at the first examination, but the lapse 
of a few weeks will clear up the doubtful points. Should the 
fibroids form knobby projections, as they most frequently do, 
abdominal palpation would contribute the requisite certainty 
to the differentiation. 

An exact diagnosis of pregnancy is often impossible even at 
the third month, but again it may be made with a reasonable 
degree of certainty. If the organ is found slightly anteflexed, 
and corresponding in size to the probable period of gestation, 
not painful to manipulation, of a peculiar softness, and, more- 
over, the woman healthy, though her menses have not appeared 
during the time, then, every probability points to the one 
conclusion. The experienced, however, usually act a wise part 
by making their diagnosis with a distinct reservation. 

At a subsequent period, differentiation of the physical condi- 
tion becomes less difficult, quickening, ballottement and the 
fuetal heart-sounds clearing away all doubt. But at the fourth 
or fifth month, though the absolute signs of pregnancy are 
absent, as in the instance of dead ovum, or uterine mole, devel- 
opment of the organ has gone to so great an extent that the 
existence or non-existence of pregnancy can be determined 
with much precision. 

In those cases where pregnancy exists in connection with 
morbid conditions, the former is sometimes overlooked, not so 
much because the symptoms of such a state are absent, as that 
they are not so prominent as those of the diseased conditions. 
The latter are generally discerned without difficulty, and 
further investigation is neglected. In these complicated cases, 
should there be a suspicion of pregnancy, repeated careful 
examinations will either confirm or remove it ; and no meas- 
ures should be adopted for the treatment of disease in women, 
which would be prejudicial to the pregnant state, without the 
possible existence of such a state being excluded. 



116 Pregnancy. 

Diagnosis of Foetal Death.— This is a highly important 
consideration. The circumstances which may give rise to a 
suspicion that the foetus is dead are : 1. Absence of foetal move- 
ments. 2. Absence of the foetal heart-sounds. 3. Diminished size 
and increased softness of the uterus. 4. Engorgement, succeeded 
by flaccidity of the mammae. 5. Sensation of weight and cold- 
ness in the abdomen. 6. Debility and general ill feeling. 7. 
Peptonuria. 

Concerning the first, we need not hesitate to declare it wholly 
unreliable, and when once active uterine effort has begun, it is 
devoid of significance. With respect to the second, it should be 
understood that in certain cases, the sounds of the foetal heart 
are inaudible for a considerable period, while yet the child is 
vigorous. The physical signs, 3 and 4, may depend upon 
causes which do not involve foetal death, while numbers 5 
and 6, being subjective symptoms, are of very slight relative 
value. Sign number 7 is said to be quite constant. 

"Certainty of death having taken place," says Schroeder, 
" is obtained only when the os is open and allows the loose 
cranial bones to be felt distinctly ; also, when the sounds of the 
foetal heart, which, in the absence of other pathological condi- 
tions, can always be distinguished by a repeated careful exami- 
nation, cannot be heard." 

Signs of Fcetal Death Evinced During Labor,— After labor 
has begun, the signs of foetal death have reference only to the 
child itself, and they are generally so clear as to dispel all doubt. 
1. The results of auscultation are almost conclusive, since, dur- 
ing parturition, the conditions favorable for the transmission 
of the foetal heart-sounds are at their best, and can hardly fail 
to be successfully made use of by even a novice. 2. On the 
head of a dead foetus no caput succedaneum is formed. The 
presence of such tumefaction is conclusive evidence of life, as 
it is the effect of long-continued pressure, and circumscribed 
arrest of circulation. 3. The scalp of a dead foetus is flabby 
and soft; the bones are movable and overlap more than 
usual ; their edges feel sharp, and on pressure communicate to 
the fingers a grating sensation. The heads of poorly nourished, 
but living children, sometimes present these peculiarities. 4. 
The presence of meconium, and the escape of thin, slimy, offen- 
sive liquor amnii, afford additional proof of death. 

If the breech presents, the sphincter ani is relaxed, and does 
not contract on the finger. The epidermis is blistered, and is 



Diagnosis of Pregnancy. 117 

easily rubbed off with the finger, if the child has been dead 
more than a day or two. This is also true of other surfaces. 

If the face presents, the lips and tongue are flabby and 
motionless. In arm presentations, there is no swelling, no 
lividity, no motion, and no warmth. In prolapse of the funis, 
the cord is flaccid, cold and pulseless. 

In rare instances cadaverous rigidity has been observed. 

Proofs of Former Pregnancy and Labor.— The permanent 
changes wrought by pregnancy and labor, which remain as evi- 
dence of the ordeal, should be remembered. 

The integument covering the abdomen, which has once been 
stretched by development that went to full term, never again 
wholly regains its tenseness, but, even during a certain degree 
of redistension due to a second pregnancy, it may be gathered 
in rolls by the hand. The silvery lines found upon it never dis- 
appear, and the new marks which may be added are, when 
fresh, of a purplish color. 

Discoloration of the areola about the nipple is more or less 
permanent, and such appearance observed in the early weeks of 
gestation should be regarded as significant, since it is not 
found primarily among the early signs. The mammae them- 
selves lose their original hardness and regular outline, often 
becoming decidedly flaccid. 

Uterine changes are marked, especially in the cervix, which 
remains permanently enlarged and the os much more patulous 
than formerly. Its cone shape is lost and it becomes more 
cylindrical. Owing to overdistension and slight laceration, the 
os presents an irregularity of surface which makes it quite dis- 
tinctive. 

The vulvar opening is larger and the carunculse myrtiformes 
are developed. 

With a knowledge of these permanent changes in mind we 
shall usually have little difficulty in determining the question 
of former pregnancy. Yet it must be remembered that these 
changes are the result of gestation which goes to a late period, 
and hence their absence is not positive evidence that pregnancy 
has never existed. After miscarriage at the third or fourth 
month, none of these evidences would be found, save perhaps 
those in the os uteri. 

Diagnosis of Foetal Presentations and Positions.— It is 
highly important to know, as early as possible after labor sets 
in, the presentation and position of the foetus. If the present- 



118 Pregnancy. 

ing part has been driven downwards into the pelvic cavity, and 
the membranes have ruptured, they can usually be learned by 
a vaginal examination, without much difficulty. But if descent 
of the presenting part has not yet been accomplished; if there 
is a tense and full bag of waters, and if the os uteri is but 
partially dilated, and is reached with difficulty, such diagnosis 
is not, in every instance, easily made even by experts. In a case 
of this kind it will be necessary to bring to our aid the informa- 
tion derivable from external examination. 

Examination through the Vagina.— In the vast majority 
of cases positive information can be gained from vaginal 
exploration alone ; but in some instances its revelations, as ordi- 
narily obtained, are most unsatisfactory. One not thoroughly 
familiar with the feel of the characters of the various presenting 
surfaces will do well to verify conclusions by external means. 

The head is recognized from its shape and hardness, which 
differ from those of any other presenting part. To the inexpe- 
rienced these may not be wholly characteristic, for students and 
young practitioners have often mistaken the head for the 
breech, and the breech for the head. The breech, when fairly 
crowded into the pelvic brim, or cavity, does give a feeling of 
resistance, which, to a casual examiner, is liable to prove 
deceptive. An attentive observer of course will rarely, if ever, 
be misled. But these remarks do not apply with equal force to 
both varieties of cephalic presentation, since the vertex pos- 
sesses characters not associated with the face. The vertex will be 
distinguished mainly by its sutures and fontanelles. As the 
finger is passed through the os uteri and rests upon a fonta- 
nelle, it is most frequently the posterior, and it will be recognized 
by its A shape, which is generally easily felt. From the apex of 
this figure the finger passes along the sagittal suture to its 
extremity, where the anterior fontanelle will be found. The 
lace will be recognized from the feel of mouth, nose, chin and 
eyes, though these features will be considerably obscured by the 
pressure to which the part is subjected, and the consequent 
tumefaction. Such presentation is more likely to be confounded 
with breech presentation than any other, and differentiation 
must be made by a detailed study of the parts, as the fingers 
are swept over them. 

When the pelvic end of the foetus is turned totheos uteri, the 
feet or knees may be in advance, or, what is more frequent, the 
breech presents. 



Diagnosis of Pregnancy. 119 

The features of this part can scarcely be mistaken. At 
first one natis only is found, but, when the os uteri opens, the 
other is felt, and the cleft between the two. The genitals, the 
point of the coccyx, the anus, and the rudimentary spines of the 
sacrum, pass under inspection, uniting to disclose the character 
of the presentation. 

In transverse presentation, the precise surface upon which 
the examining finger falls can generally be made out, though 
not always with facility. The side should be recognized from 
feeling the ribs, and the shoulder by finding the scapula and 
vertebrae, and by its own peculiar contour. In early examination 
the presenting part often lies entirely out of reach. This is a 
diagnostic fact of much value. 

Upon examining per vaginam in these cases, we find, when 
the feet or knees present, that, early in labor, diagnosis is many 
times a matter of some difficulty, inasmuch as an extremity 
is felt, but it moves before the finger, and will not admit of 
tactile study. Later, however, it comes within reach, some- 
times suddenly, by rupture of the membranes, and escape 
of the liquor amnii. The foot is distinguished mainly by the 
toes and heel, and the knees are known from their size, and 
obtuseness. 

When the presentation is either transverse or pelvic, the bag 
of waters is larger and longer,* and thorough exploration corre- 
spondingly difficult. 

Diagnosis of Presentation and Position by Abdominal 
Palpation.— This subject ha 4 received considerable attention 
of late, and its value during pregnancy, for the purpose of 
diagnosis, has been clearly demonstrated. Dr. Paul F. Munde 
has furnished a most interesting and valuable paper on the 
subject, with some very excellent illustrations. Dr. De Paul has 
likewise given some important instruction concerning its value 
and methods, with figures. 

According to the writers mentioned, and others, a little prac- 
tice will enable one to elicit, by means of abdominal palpation, 
most valuable information concerning both presentation and 
position of the foetus. Examination ought first to be with 
reference to the direction of the long uterine axis. If that corre- 
sponds closely with the longitudinal axis of the woman's body, 
the presentation must be either cephalic or pelvic. By spread- 

*This clinical sign has its exceptions; hence, while possessing intrinsic value, it is 
not to be regarded as pathognomonic. 



120 



Pregnancy. 



ing the hands over the uterus, a sense of greater resist- 
ance and fullness can generally be felt more to one side or the 
other, which represents the situation of the foetal back. By deep 




Fig. 88. 



palpation with a single hand on the hypogastrium, the head of 
the foetus, if presenting, can be felt, and recognized by its form 




Fig. 89. 



and hardness. By striking the tips of the fingers suddenly 
inwards at the fundus, the breech can generally be made out, or 
the head, if there, be felt still more easily. It is also possible, in 



Diagnosis of Pregnancy. 



121 



most cases, to find the foetal limbs, especially on provoking 
movements. When the fetus lies in a transverse presentation, 
diagnosis is still less difficult. The long foetal axis being thrown 
across the abdomen, gives to the part a feel wholly different 
from that found in connection with other presentations. The 
cephalic globe can easily be fingered in one iliac fossa or the 
other, or at a higher point. 

Diagnosis of Presentation and Position by Abdominal 
Auscultation. — This is another means of diagnosis not 
properly valued or understood by obstetric practitioners. For 
general purposes the unaided ear will answer very well ; but for 




Fig. 90. 
the diagnosis of presentation and position, the stethoscope is a 
necessity, as without it the summum of intensity of the sounds 
cannot be circumscribed. The most common location of the 
foetal heart-sounds is on the left side below the umbilicus, 
1. Because the back of the child is most frequently turned to- 
wards the mother's left, and 2. Because the head commonly 
presents at the os uteri. The first fact, then, to be kept in 
mind is that when the foetal back is turned towards the left side 
of the mother, the heart-souuds will be most distinctly audible 
on that side. The just inference to be drawn from this is not 
that the position is necessarily a left dorso-anterior one, though 
it is more likely to be. It may be a left dorso-posterior posi- 
tion, with but a moderate inclination backwards. Accordingly 
we conclude when the sounds of the foetal heart are most dis- 
tinct on the mother's left side, that the position is either a left 



122 



Pregnancy. 



dorso-anterior, or a left dorso-posterior position; in other 
words, it is a first or a fourth position, with the probabilities 
strongly in favor of the former. If heard most clearly at a 
point an inch or more below the line of the umbilicus, the 
woman being near term, it is a cephalic presentation ; if heard 
most distinctly at a point as high as the umbilicus, or higher, 
it is a breech presentation. When the summum of intensity of 
the foetal heart-beat is on the right side, the position is either 

right dorso-anterior, or right dorso- 
posterior ; or, in other words, it is 
either a second or a third position, 
without regard to the presentation. 
But now, if the point of clearest 
audibility is on or below a line 
drawn transversely across the ab- 
domen about an inch below the um- 
bilicus, the woman being near term, 
it is almost certainly a cephalic pre- 
sentation. If the sounds are most 
distinctly audible at a point above 
the umbilicus, it is equally certain 
that the presentation is pelvic. 

In transverse presentation the 
foetal heart is heard most distinctly 
on or near the median line of the 
abdomen, several inches below the 
umbilicus. 

Diagnosis of Twin Pregnancy- 
through Auscultation.— In twin 
pregnancy, the foetuses lie upon 
either side of the abdomen, and 
from mere inspection a diagnosis 
can sometimes be made. The 
stethoscope will be applied to one side, perhaps the left, below 
the umbilicus, and the sounds there heard counted by the 
watch. The investigation is still further pursued, and on the 
opposite side of the abdomen, perhaps on a line with the first 
sounds, but more likely at a higher point, a foetal heart of a 
different rhythm is heard, and its pulsations counted. From 
such an examination we infer with great confidence that there 
are two foetuses in utero, and furthermore that their positions, 
and perhaps their presentations, vary. The same principles of 




Fig. 91.— Showing at + the 
most common locations of the 
foetal Heart-sounds. 



Diagnosis of Pregnancy. 



123 



diagnosis of presentation and position are here involved, as in 
the instance of single pregnancy. In the same connection it 






Fig. 92. — First posi- Fig. 93— First posi- Fig. 94. — First posi- 

tion of the Vertex. tion of the Face. Lo- tion of the Breech. 
Location of heart- cation of heart-sounds Location of heart- 



sounds indicated by 



indicated by -{-. 



sounds indicated by -(-. 




Fig. 95. — Dorso-anterior posi- 
tion of Transverse Presentation. 
Location of heart-sounds indi- 
cated by +. 




Fig. 96. — Twin Pregnancy. Lo- 
cation of heart-sounds indicated 
by+- 



should be borne in mind that the dorsal surfaces in twin preg- 
nancy, are, as a rule, turned in opposite directions. 



124 Pregnancy. 

The presentations are also different in about forty per cent, 
of twin pregnancies, so that the heart-sounds are most fre- 
quently found at corresponding heights on the abdomen. 

These ideas of presentation and position, derivable from pal- 
pation and auscultation, are not theoretical merely, but highly 
practical, as the author has demonstrated in hundreds of cases 
within the Obstetrical Department of Hahnemann Hospital, 
Chicago, as well as in private practice. 

Diagnosis of Sex from Rapidity of the Foetal Heart — 
The possibility of determining with tolerable accuracy the sex 
of the foetus in utero from the rapidity of the heart's action, 
has commanded the confidence of some, and is deserving of 
study. The theory is founded on the clinical observation that 
the heart of the female fcetus exceeds in rapidity of pulsation 
that of the male. That there is an element of truth in the 
theory is plainly shown by the reports of all who have given 
the matter attention, but experience of different observers has, 
nevertheless, been far from uniform. Steinbach was correct in 
forty-five out of fifty-seven cases which he examined, and 
Frank en hseuser made not a single mistake in fifty consecutive 
cases. But other careful observers fall far short of such mar- 
velous success. 

In studying the subject, one should not forget the influence 
of both maternal and fcetal states upon the heart's action. It 
is probably as true of intra- as of extra-uterine life, that such 
influences much more frequently accelerate than retard the 
cardiac contractions, and hence we often find the male heart 
simulating, in point of rapidity, the female heart. This affords 
a rational explanation of the greater relative frequency of 
males when the pulsations fall below 135% to the minute, than 
of females when the pulsations exceed that number. That dis- 
turbance of the vital force of the foetus, and its reduction to a 
low ebb, is exhibited in the pulsations, is clearly shown in 
carefully conducted observations. An instance of the kind 
appears in the succeeding tables. The mother was in very 
feeble health, and, tAvo weeks prior to delivery, the heart of 
a male foetus which she bore was pulsating so rapidly that it 
could scarcely be followed — 1 72 times a minute. The child was 
still-born, near term, and presented evidence of life having been 
extinct for several days. 

The author's personal observations in ninety-six unselected 
cases gave an average pulsation of 135%. The results of obser- 



Diagnosis of Pregnancy. 125 

vations, with this as the intermediate point in the scale, are 
given in the accompanying table : 

Pulsations in excess of 135}^ 
Pulsations below lSb)4 • • 



Male. 


Female 


25 


24 


35 


12 


60 


36 




. 134 




138 



Total ' . 

Average pulsations of males 
Average pulsations of females 

According to these figures it will be observed that if diag- 
noses of sex had been made in accordance with the theory of 
cardiac rapidity alone, they would have been correct in only 
fifty-nine out of ninety-six cases, or in but little more than 
sixty-one per cent, of them. 

As the proportion of males in these ninety -six cases is so far 
in excess of females, it appears that a comparative statement, 
constituting in some regards a more equitable showing, should 
be based on an equal number of males and females. In order 
to present such a table, we have taken the entire number of 
females (36), and compared it with a like number of males 
taken in regular order from the records, first in chronological 
order, and secondly in reverse order, with the following results: 

Comparative Statement op the Foltal Heart-sounds in Thirty-Six 
Males, taken in Chronological Order from the Author's Records, 
and those of the Entire Thirty-six Females in the Foregoing List : 

Cases wherein the pulsations exceeded the 

average number of 135)^ per minute : 

Males, 14 — about 37 per cent. 
Females, 24 — about 63 per cent. 
Cases wherein the pulsations fell below the 

average number of 13b% P© r minute : 

Males, 22 — about 65 per cent. 
Females, 12 — about 35 per cent. 

A Comparative Statement Similar to the Foregoing, the Thirty-six 
Males being taken from the Records in Reverse Chronological 
Order : 

Cases wherein the pulsations exceeded the 

average number of 1353^ per minute : 

Males, 13 — about 34 per cent. 
Females, 25 — about 66 per cent. 
Cases wherein the pulsations fell below the 

average number of ISS^ per minute: 

Males, 23 — about 68 per cent. 
Females, 11 — about 32 per cent. 



126 



Pregnancy. 



These observations were made in hospital practice, and the 
unusual proportion of male children is not easily explained on 
any other basis than the recognized preponderance of that sex 
among the illegitimate : 



Pulsations of 
Foetal Heart. 

110 

116 

120 

122 

124 

126 

128 

130 

132 

134 

136 



Totals 



Mother' 
Age. 
14 . 
16 

17 . 
18 
19 
20 
21 
22 
23 
24 
25 



Average 
Pulsations 
. 120 

141 
. 136 

137 
. 135 

138 
. 137 

132 
. 145t 

137 
. 130 



Totals 



Male. Female. 



1 
1 

4 
1 
5 
3 
10 
5 
5 

9 



Pulsations of 
Fcetal Heart. 

138 

140 

142 

144 

146 

148 

150 

160 

162 

172* 



Male. 


Female. 


Mother's 
Age. 
26 





1 


1 


2 


27 . 


3 


2 


28 


1 


2 


29 . 


. 4 


3 


30 


6 


4 


32 . 


. 8 


5 


34 


13 


2 


35 . 


. 5 


1 


37 


5 


2 


38 . 


. 2 


1 





Average 
Pulsations. 
144 
126 . 
136 
123 . 
134 
136 . 
136 
142 . 
160 
132 . 



Male. Female 
. 4 2 

9 6 

. 5 

2 
. 1 


. 



. 1 

1 

60 



5 

1 
4 
1 
1 
1 


36 



Male. Female. 



1 
2 

1 
3 

2 
1 
1 


1 

60 



1 

2 

5 



1 

2 


36 



*Case of dying foetus mentioned 
f Dying foetus raised the average. 



Duration of Pregnancy. 127 

CHAPTER V. 

THE DURATION OF PREGNANCY. 

This is a subject which has elicited much study and discus- 
sion. In settling it on a firm scientific basis, the main obsta- 
cle has been the impossibility to ascertain the precise date of 
fertile coitus. In hospital practice, the majority of women 
entered for confinement are living outside the conjugal relation- 
ship; have been leading lives of repeated exposure to impreg- 
nation, and are unable to offer positive testimony as to the 
date of conception, even if so disposed to do. Others, both 
in and out of hospitals, who are unmarried, profess to 
have been guilty of but a single misstep, and are prepared to 
give precise dates; but we must withhold from such full cre- 
dence, since the motive prompting v them to misrepresentation is 
so powerful. The married state presents obstacles to absolute 
calculation fully as great as those just enumerated. On 
account of the difficulties in the way of trustworthy observa- 
tion, it has become customary to base calculations on the date 
of the last menstruation. The fallacies associated with such 
figures are conspicuous. First, the date of the last menstrual 
return cannot be held to represent the real time of impregna- 
tion, or even of insemination, in more than a very small per- 
centage of cases, since sexual congress during menstruation is 
avoided by both parties to the act. Moreover, the time of 
insemination does not correspond to the date of impregnation, 
inasmuch as the time consumed by the spermatozoa in journey- 
ing from the vagina to the point of contact with the ovum 
represents a period varying from a few hours to a few days. 
Again, it is admitted by physiologists that fertile coitus may 
both precede and succeed the menstrual return, by a few days. 
Should it precede, the flow which was so near maybe prevented, 
and a miscalculation made by basing the figures on the date 
of the last menstruation. Or the flow may come on at the 
usual time, even though impregnation has existed for several 
days. Allusion should here be made, also, to those anomalous 
cases wherein conception is succeeded for two, three, or four 
mouths by regular menstrual returns. Hence it appears that, 
at best, such a basis of calculation is not settled nor reassuring. 

We gather some information concerning the average dura- 
tion of pregnancy from a studj^ of comparative physiology. 



128 Pregnancy. 

Valuable observations have been made in the case of certain 
domestic animals, in whom one coitus coincides with the period 
of rut. In 1819, M. Tessier submitted to the Academie des 
Sciences at Paris the results of a series of investigations of this 
nature, which are worthy of attention. Of 140 cows — 

14 calved between the 241st and the 266th day. 
53 " " " 269th " 280th " 
68 " " " 280th " 290th " 
5 " " " 290th " 308th " 

Gestation in cows is but little more protracted than in 
women, and according to this table, founded on exact observa- 
tions, there was an extreme difference in duration of pregnancy 
amounting to 67 days. Lord Spencer made a series of obser- 
vations of a similar nature in the case of mares. Of 102 mares — 
3 foaled on the 311th day. 



1 


a «i 




314th " 


1 


a « 




325th " 


1 


« u 




326th " 


2 


it u 




330th " 


47 


" between the 340th and 350th day. 


25 


it it 


. " 


356th " 360th " 


21 


it u 


tt 


360th " 377th " 


1 


on 


u 


394th day. 



In neither of these tables has allowance been made for the 
contingency of premature labor, which probably widens the 
extremes ; but when a reasonable number has been deducted, on 
the strength of this presumption, there still remains evidence 
of widely variable results. It may be said in favor of the tables 
as exhibited, that, in the animals mentioned, it is highly prob- 
able that the influences generally regarded as productive of 
premature labor were not as numerous, nor as powerful, as 
those to which women are subjected. 

Dr. Eeid collected thirty-nine, and Dr. Montgomery fifty-six 
cases, in which pregnancy was calculated from a single coitus, 
with the following results : 

Reid. Montgomery. Total. Duration. 

36 weeks, or 252 days. 






1 


1 


1 


2 


3 


6 


2 


8 


7 


10 , 


17 


8 . 


22 


40 


2 


9 


11 


3 


8 


11 


2—39 


2—56 


4—95 



37 

38 
39 
40 
41 
42 
43 



259 
266 
273 
280 
287 
294 
301 



Duration of Pregnancy. 129 

While there are grave doubts of accuracy in many of 
these cases, and hence of the table as a whole, some of them 
are worthy of most implicit trust. Dr. Montgomery relates the 
case of a lady who went to the sea-side in June, 1831, leaving 
her husband in town. He visited her for the first time Novem- 
ber 10th, and returned to town on the succeeding day. She 
quickened on the 29th of January, 1832. and was delivered 
August 17th, exactly two hundred and eighty days from 
the time of the last sexual intercourse, which was preceded by 
an interval of nearly five months. 

Considering the remarkable care and precision exercised by 
these observers, it seems probable that the results, as shown, 
approximate very closely the real facts, and from them we learn 
that there is a wide variation in the duration of pregnancy. In 
addition to the above, there are several cases recorded where 
delivery of what appeared to be fully developed children occur- 
red as earlv as 260, and as late as 284 davs after a single 
coitus, so that we are led to conclude that pregnancy does not 
run a course with uniform limits. 

Schlichting has examined -156 cases in which the day of copu- 
lation was known, and in which the children were full term. 
He found an average duration of 270 days, but the extremes 
were very wide. 

But as it is rarely possible to determine the date of fertile 
coitus, the calculation and experience of the duration of preg- 
nancy must rest chiefly on observations, the starting point of 
which is the last day of the last menstruation. Dr. Merriman 
has accordingly conducted and recorded a series of investiga- 
tions, which are here tabulated. Of the 150 mature births 
observed by him — 

5 were delivered in the 

16 '• 

21 fc ■■ " 

46 " 

23 " 

18 " 

11 " 

5 " 

A difference of fifty-one days between extremes is here 
shown. Dr. James Reid has given a table of 500 cases, in which 

(9) 



37th 


*veek 




255th to 259th day. 


38th 






260th to 266th " 


39th 


" 




267th to 273rd " 


40th 


K 




274th to 280th " 


41st 


<: 




281st to 287th " 


42d 


u 




288th to 294th " 


43d 


" 




295th to 301st " 


44th 


" 


the latest 


being the 306th day. 



130 



Pregnancy. 



the calculation is also from the last day of menstruation. 

Of these — 



48 
81 
131 
112 
63 
28 



37th week . 


. 255th to 259th day 


38th " 


260th to 266th " 


39th " 


. 267th to 273d " 


40th " 


274th to 280th " 


41st " 


. 281st to 287th " 


42d 


288th to 294th " 


43d " 


. 295th to 301st " 


44th " 


302d to 308th " 


45th " 


. 309th to 315th " 



The difference between extremes is here sixty days. With 
these, and other equally reliable facts before us, we are led to 
the conclusion that the average duration of pregnaucy is in the 
vicinity of 278 days, though the variations are extensive. 

The Minimum. — It is interesting and important to know 
what is the shortest time within which a child may be born 
alive, and have a fair chance of life. In cases of contemplated 
induction of premature labor for conservative purposes, the 
minimum time allowed the foetus is 230 to 250 days, but cases 
are on record in which life has been sustained when birth took 
place at a much earlier period. The following table by Dr. 
Montgomery will prove of interest because of the information 
on this subject which it affords : 



TO. 


Last Date of 
Menses. Concep'n. 


Birth. 


Duration 
of Gest'n. 


Days 


Survival of Child. 


1 


Oct. 9 Oct. 9 


Apr. 3 


5 M. 10 D. 


161 


Twelve hours. 


2 


Aug. 24 
married 


Mar. 3 


5 " 21 " 


174 


A week. 


3 


July 22 
married 


Jan. 18 


5 " 27 " 


180 


131 days. 


4 






6 " 


183 


Seven weeks. 


5 


Apr. 10 Apr. 10 


Oct. 16 


6 " 9 " 


189 


Eleven years. 


6 


Apr. 1 


Oct. 10 


6 " 13 " ( 


193 


Doing well 6 m. afterward 


7 


Jan. 31 


Aug. 14 


6 " 16 " ' 


196 


Thirty years. 


8 


Jun. 12 


Dec. 27 


6 " 18 " 


198 


Two years. 


9 


Oct. 24 


May 10 


6 " 19 " 


199 


Eleven days. 





Aug. 22 


Mar. 18 


6 " 21 " 


201 


Thirteen years. 



The Maximum.— That pregnancy is sometimes protracted 
beyond the usual period seems now an established fact. We 
are nevertheless told that little more than fifty years ago 
opinions very different from those which now prevail were held 
by the best obstetricians. In the Gardner peerage case which came 



Duration of Pregnancy. 131 

before the House of Lords, England, in 1825, Drs. Gooch and 
Davis, and Sir C. Clark, testified that, in their judgment, the 
period of 280 days was never exceeded. Subsequently, with a 
view to ascertain the experience of those who were most likely 
to have paid particular attention to the subject, upwards of 
forty of the most eminent obstetric practitioners in London, 
Dublin and Edinburgh, were applied to by Dr. Reid. The large 
majority of these expressed a firm conviction as to the occasional 
extension of the usual period of pregnancy by a few days be- 
yond 280. Several had met with one or two cases of protracted 
gestation, out of many hundred, on the exact data of which 
they could rely ; others, who had not kept notes of their cases, 
could not offer positive testimony, but had no doubt that in 
some cases the period had been extended. Some, who had had 
extensive private and hospital practice, stated that they had 
never met with an undoubted case of protracted gestation; 
while two affirmed their strong conviction that no case ever ex- 
ceeds the 280th day from conception, and one, that pregnancy 
is never carried beyond the ninth calendar month. 

Without permitting this subject to take up too much space, 
it may be remarked that there are on record undoubted cases 
of protracted gestation, though they are probably rarely met. 
Many of the cases adduced are valueless, because founded on 
insufficient data, but cases have been reported which merit our 
acceptance. 

There are many careful observers who put no credence in 
alleged examples of prolonged gestation. " We therefore say," 
remarks Charpentier, " with all other authors, that prolonged 
pregnancy, the foetus being alive, does not exist as a physiologi- 
cal condition. It exists only in cases like the following: 1. In- 
extra-uterine pregnancy ; 2, In cases of dead foetus retained in 
utero, as in instance of abortive ova; 3. Finally, in cases 
where a dead foetus is retained by obstacles to parturition 
seated at the cervix. Even in such cases, prolonged pregnancy 
is very exceptional." 

Prediction of Date of Confinement.— The average dura- 
tion of gestation after cessation of the menstrual flow, has been 
found to be 278 days. Various methods of calculation have 
been suggested, and sundry periodoscopes and tables have 
been given, with a view to facilitate the prediction, and make 
it more accurate than it could be without them, some of which 
are based on an average of 278 and some of 280 days. 



132 



Pregnancy. 



Dr. Matthews Duncan, who has devoted much study to the 
prediction of the time of labor, has given a method of calcula- 
tion based on an average of 278 days, which is very convenient 
and practical. His rule is : " Find the day on which the female 
ceased to menstruate, or the first day of being what she calls 
* well.' Take that day nine months forward as 275, unless Feb- 
ruary is included, in which case it is taken as 273 days. To this 
add three days in the former case, or five if February is in the 
count, to make up the 278. This 278th day should then be fixed 
on as the middle of the week, or, to make the prediction more 
accurate, of the fortnight in which the confinement is likely to 
occur, by which means allowance is made for the average varia- 
tion of either excess or deficiency. 

Naegele's method is to figure from the first day of the last 
menstrual period, and then count forwards nine months, or 
backwards three months, and to this date add seven da} T s to 
complete the period of 280 days. 

The following table by Dr. Protheroe Smith is easily under- 
stood, and is probably fully as serviceable as any : 

Table for Calculating the Period of LFtero-Gestation. 





Nine Calendar Months. 




Ten Lunar Months. 




From 


To 


Days. 


To 


Days. 


January 1 . 


. September 30 . 


. 273 . 


. October 7 . 


. 280 


February 1 


October 31 . 


273 


November 7 . 


280 


March 1 


. November 30 . 


. 275 . 


. December 5 


. 280 


April 1 


December 31 


275 


January 5 


280 


May 1 . 


. January 31 


. 276 . 


February 4 


. 280 


June 1 


February 28 


273 


March 7 . 


280 


July 1 . 


. March 31 . 


. 274 . 


. April 6 


. 280 


August 1 


April 30 . . 


273 


May 7 


280 


September 1 


. May 31 . 


. 273 . 


. June 7 . 


. 280 


October 1 


June 30 


273 


July 7 


280 


November 1 


. July 31 . 


273 . 


. August 7 


. 280 


December 1 


August 31 


274 


September 6 . 


280 



The above obstetric " Ready Reckoner," consists of two columns, one of calendar, 
the other of lunar months, and may be read as follows : A patient has ceased to menstru- 
ate on July 1; her confinement maybe expected at soonest about March 31 (the end of 
nine calendar months), or at latest April 6 (the end of ten lunar months). Another has ceased 
to menstruate on January 20 ; her confinement may be expected on September 30, plus 20 
days {the end of nine .calendar months) . at soonest; or on October 7. plus 20 days (the end of 
ten lunar months), at latest. 

The Date of Quickening. — Even when it is impossible to 
establish the date of the last menstrual period, the time of 
quickening can sometimes be recalled by the woman, in which 
case it is customary to add twenty-two weeks for the purpose 



Duration of Pregnancy. 



133 



of determining the proximate day of delivery. But quickening 
is a sign of pregnancy which does not always develop in the 
eighteenth week, and the extreme variation in its manifestation 
in different women and different pregnancies, renders this 
method of calculation a very uncertain one. We have heard 
patients declare that movements were felt in certain pregnan- 
cies as early as the third month, while others were not conscious 
of them until the fifth or sixth month. 

Prediction of Time of Labor from Size of Uterus.— From 
abdominal palpation we may gather important data upon 
which to venture a prediction of the time of expected confine- 
ment. According to common bed- i 
side teaching, the uterus in the I 
second month is of the size of an \ 
orange; in the third month, of the \ 
size of a child's head ; in the fourth \ 
month, of the size of a man's head, I 
and can be felt above the sym- / 
physis pubis. In the fifth month, / 
the fundus of the uterus rises to a / 
point midway between the sym- / 
physis and the navel. By the sixth 
month it reaches the level of the V 
navel. In the seventh month, it V 
should be the breadth of two or \ 
three fingers above the navel. In \ 
the eighth month, it mounts to a Fig. 97.— Size of the Uterus 
point half-way between the navel at various periods of preg- 
and the epigastrium. In the ninth nanc y- 
month it reaches the epigastrium. In the tenth month, two or 
three weeks before confinement, the uterus sinks downward 
and somewhat forward, so that its upper level corresponds 
very nearly to that of the uterus in the eighth month. 

The fallacy in this mode of describing the progress of uterine 
development, as discovered through the abdominal parietes, is 
that the navel is not a fixed point, and its distance from the 
symphysis is steadily increased up to a late period in preg- 
nancy. A more accurate manner of describing the height of 
the fundus is followed by Spiegelberg with the following results : 




From the 22d to the 26th week 

" " 22d to the 28th week 

" 22d to the 30th week 



%% inches. 
11 



134 Pregnancy. 

From the 22d to the 32d and 33d weeks . 11>£ "inches. 
" 22d to the 34th week ... 12 

" 22d to the 35th and 36th weeks . 12% 
" 22d to the 37th and 38th weeks .13 
" 22d to the 39th and 40th weeks . 13^ 

The size of the uterus varies greatly in different women at the 
same stage of gestation, but the above average measurements 
are somewhat excessive. From accurate recorded observations 
made by the author, the figures which approximate the true 
average more closely are those which follow : 



From the 16th to the 20th week 


6 


to 6% 


inches. 


" 20th to the 24th week . 


' . 7 


to 8 


a 


" " 24th to the 28th week 


9^ 


to 10 


" 


" 28th to the 32d week . 


. 10 


to 10>£ 


" 


" " 32d to the 36th week 


11 


tollK 


a 


" 36th to the 40th week . 


. 12 


tol2K 


" 



The facts here presented may aid materially, when taken in 
connection with other conditions, in fixing upon the probable 
time of delivery. 



PSEUDOCYESIS. 135 

CHAPTER VI. 

PSEUDOCYESIS. 

Pseudocyesis— false, spurious, or phantom pregnancy — has 
been defined by one as a "mental delusion, resulting in a false 
interpretation of bodily sensations, experienced for the most 
part in the abdomen/' It may be justly regarded as a 
delusory conviction of pregnancy, based upon, or giving rise to, 
symptoms which, in some instances, closely resemble those of 
true gestation. It is not always a mere assumption which will 
readily yield to the force of an ordinary negative from the 
medical attendant; but a settled conviction, strong enough to 
divert the course of nervous impulses, and thereby magnify or 
develop presumptive symptoms of pregnancy, and, sometimes, 
even parturition. A similar mental impression may lead a 
woman to believe that she is the subject of an abdominal 
tumor. 

Care should be taken not to confound spurious pregnancy 
with "false conception," since there is a wide difference between 
the two states, the latter being nothing more nor less than 
molar pregnancy. 

Dr. Matthews Duncan directs attention to the fact that some 
of the lower animals, such as bitches, exhibit signs of spurious 
parturition. Reviewing the subject of pseudo-pregnancy, in his 
terse and lucid manner, he very properly, as we believe, em- 
phasizes the thought that distinction ought to be made between 
those cases where there is merely spurious pregnancy, and those 
in which the patient's vivid imagination, strong with the delu- 
sion, carries her to a culmination of the supposed pregnancy 
in fancied or spurious labor. Dr. Reamy mentions a case where 
not only was a midwife kept two nights watching by the bedside 
of a woman who was the subject of phantom pregnancy, but a 
practitioner, doing a large business, actually shared with the 
midwife for several hours, the honor of supporting the perineum. 
Both declared that not only were the pains severe, but that 
the perineum actually bulged from what was supposed to be 
the foetal head. 

Conditions of Development.— The anomaly of spurious 
pregnancy is observed in women of various ages. Dr. O'Far- 
rall mentions a case which occurred in a girl of only 



136 Pregnancy. 

thirteen years. Dr. Churchill records one which happened in a 
young lady of seventeen.* Sir J. Y. Simpson, who was the 
first to give a detailed description of spurious pregnancy, eluci- 
date its causes, and prescribe its treatment, thinks the com- 
plaint is as frequent the first year after marriage as at any 
other time. Dr. Montgomery believes it to be most frequent at 
the climacteric period. Melancholy instances of the kind have 
been observed in aged spinsters and widows, who had long 
passed the menopause, in whom life was rendered intol- 
erable by reason of this harrowing delusion. 

Etiology. — The excesses of early married life, and the phys- 
ical and psychical changes incident to this period in a woman's 
existence, afford, in the susceptible, an excellent basis upon 
which to frame a false conviction of pregnancy. The same is 
also true of the disturbed physical and mental equilibrium at- 
tendant on the climacteric period. It seems clear, also, that a 
consciousness in the unmarried of having been exposed to the 
risk of impregnation, and the impugnings of a guilty con- 
science, contribute to settle and fix the unpleasant delusion. 

The latter may operate as powerful predisponents to the 
physical and mental states and symptoms which point so im- 
pressively to a pregnant condition; but it is probable that in 
many instances there is a transposition of cause and effect. In 
one example, the physical symptoms which characterize the 
case are doubtless the result of a previous mental state, being 
physical expressions and sequences of a settled delusion, while 

*The remarkable influence of mind over bodily states, evincing itself in the develop- 
ment of physical signs of pregnancy, is so well illustrated in the following case, reported 
by Dr. Reamy, that we give it in full : " A beautiful and refined girl, 20 years of age, from 
an adjoining State, was placed under my charge. She imagined that, on a certain night, 
specified and clearly designated circumstantially to her mother and a married sister, her 
room had been entered by two men, one of whom had chloroformed and the other ruined 
her. She had read a few days before a false and sensational article detailing the partic- 
ulars of a similar atrocity. When I examined her four months after her supposed 
pregnancy had occurred, she was pale, anaemic, nervous, amenorrhceal. Her countenance 
was the picture of despair. At times the abdomen was large, then decidedly flat. The 
mammae were swollen, and contained milk. She suffered from nausea every morning and 
was conscious that for the past few days she had felt violent movements in the abdomen. 
The friends were constantly in dread that she might commit suicide. Ferruginous tonics 
with generous diet, bathing, air, exercise, etc., were tried without avail. Her general health 
did not improve, and no argument or assurance could convince her of her delusion. On 
every other subject she was perfectly rational. Finally, after five months from the date of 
her supposed pregnancy had elapsed, I took into her room a manikin, the articulated bony 
and ligamentous pelvis, with Schultz's obstetrical plates. I, by this means, succeeded in 
demonstrating to. her the impossibility of pregnancy at five months' advancement with- 
out greater abdominal enlargement. I spent in this demonstration at least an hour, going 
over and over the ground. It was in the presence of her mother. Success rewarded me. 
She was convinced of her delusion. The fear never returned. She gained eighteen 
pounds in weight in three weeks. The menstrual function was at once established." 



PSEUDOCYESIS. 137 

in another, the mental impression is, as in real pregnancy, con- 
secutive on observed physical conditions. In the latter in- 
stance, it is doubtless true that the bodily state is modified in 
great measure by the rooted notion which originated from 
physical phenomena. Dr. Simpson says that "the aggregate 
of the symptoms which we class under the designation of spu- 
rious pregnancy in women, is in some way or other dependent 
upon the changes which occur in the ovaries and in the uterus 
at the period of menstruation." Another careful observer re- 
marks that " it will be found that in most of those persons who 
fancy themselves pregnant, there is a marked derangement of 
the circulatory, digestive and nervous systems, either one or 
all being usually implicated." 

Symptoms. — The phenomena observed in spurious preg- 
nancy are worthy a careful study. Tn the majority of cases, 
there is unusual flatulence, and some writers have accordingly 
attributed the abdominal symptoms to this condition. 
Simpson does not incline to that view, but regards the phe- 
nomenon of abdominal distension as probably dependent 
"on some affection of the diaphragm which is thrown into a 
state of contraction, and pushes the bowels downwards into the 
abdominal cavity." There is tympanites ; but it is not evident 
from reported cases that either the area of resonance, or the 
percussion note, differs essentially from that often met in the 
non-pregnant state. Increased prominence of the abdomen in 
some cases can be justly attributed to deposition of adipose in 
the abdominal parietes and omentum. 

The movements which so closely simulate those of a foetus 
are probably produced in some cases by flatus in the intestines ; 
but they are oftener due to spasmodic muscular action. Dr. B. 
F. Betts relates a case wherein the movements were so vigor- 
ous as to be discernible through the clothing. 

"By application of the palmar surface of the hands to the 
abdominal walls," says the doctor, "the recti muscles were 
found to be irregularly contracting, so as to appear at first as 
though they were pressed out by the movements of a child in 
utero, at irregular intervals. From an inspection, it was im- 
possible to distinguish these contractions from the real move- 
ments of a foetus, but by palpation, the tendinous attachments 
of the muscles to the brim of the pelvis were felt to be stretched, 
as from strong muscular contractions." 

In some cases the abdomen is swollen to an extreme degree, 



138 Pregnancy. 

but these are exceptions to the rule. In palpating, the hand 
may meet with resistance, but this generally arises from con- 
traction of the broad, flat muscles of that region. In a few 
reported instances there was a certain amount of tumefaction, 
which assumed the outline of a pregnant uterus. 

Pseudo-pregnancy may continue for only a few weeks, and 
then wholly vanish, or it may persist for seven, nine, twelve or 
even eighteen months— perhaps longer. The similarity of some 
of the manifestations to those of certain nervous disorders of a 
hysterical type should not be overlooked. The strong mental 
impression, the exaggeration of sensations and conditions, the 
flatulency so often observed, and the state of nervous exulta- 
tion, are all of this nature. 

Diagnosis.— The diagnosis of pseudocyesis will vary in pre- 
cision according to the period of development which has been 
reached at the time of examination. In early gestation we have 
relative signs only upon which to base our opinions, and these, 
though in certain combinations they lend strong probability to 
our deductions, afford, after all, nothing more than presump- 
tive evidence. A notion of existing pregnancy takes possession 
of a woman, and she presents herself for diagnosis. Gestation, 
if begun, is two or three months advanced. Some of the rela- 
tive signs of that condition are found, giving color to the 
presumption, but the discreet physician will not express an un- 
qualified opinion. On the contrary, there may be an absence 
of the most common presumptive signs of pregnancy, yet an 
unequivocal diagnosis of non-pregnancy would be unwise. At 
a later period a physical examination ought to yield unmistak- 
able results. Abdominal distension, due to a tumor of some 
sort, may create in the woman's mind a conviction of preg- 
nancy not easily eradicable, and symptoms closely resembling 
those of pregnancy follow on apace. In such cases the quar- 
tette of signs pathognomonic of the real condition, namely, 
foetal movements, ballottement, foetal heart-sounds and rhyth- 
mical uterine contractions, will go far to clear up the doubtful 
points. 

It is not always possible to make a satisfactory examination 
in a case of doubtful pregnancy, without first bringing the 
woman under anaesthetic influences. When this has been done, 
since by it flatulency will in great measure be overcome, mus- 
cular spasm subdued and sensibility annulled, the abdomen 
will offer no resistance to deep palpation, nor the vagina to 



PSEUDOCYESIS. 139 

thorough exploration, affording thereby conditions the most 
favorable for diagnosis. 

Mention should also be made of the asymmetry, and incom- 
pleteness in the order of development and mutual relation of 
the signs. There is a lack of harmony in the assemblage of 
the phenomena, an irregularity or defect in the sequence, the 
grouping, and the character of the symptoms, creating in the 
observer an impression unlike that derived from a clinical study 
of the signs of real pregnancy. This is especialh' true with 
regard to the menstrual function, which is rarely suspended for 
the entire period. It is also worthy of notice that movements, 
inferentially foetal, in many of these cases, are felt much earlier 
than those of real pregnancy. 

Treatment.— The delusion which enthralls women in these 
interesting cases is not always easily removed. If a subject has 
confidence in her medical adviser, she will be persuaded, though 
perhaps reluctantly, to cast away her erroneous notions. It 
may be necessary for him to point out and elucidate the prem- 
ises upon which his conclusions are based, and such an appeal 
to her reason will generally avail. In those cases where the 
conviction of pregnancy was derived from logical conclusions 
based upon insufficient data, theremay not be marked physical 
improvement, even after the delusion has been dispelled, with- 
out suitable medicinal treatment. 

If there was antecedent menstrual suppression, Pulsatilla, 
caulophyllum , apis or sulphur, may be required to regulate 
functional activity in the generative sphere. 

If the digestive apparatus is disordered, giving rise to flatu- 
lence, china, lycopodium, nux vomica, mix moschata, or carbo 
vegetabilis, may be needed. 

If marked physical disturbance is found, we are more likely 
to unravel the tangled case by giving the symptoms arising 
therefrom a dominating influence in a selection of remedies. In 
the absence of these, or if we have good reason to believe that 
functional disorder is due to psychic influence, then the men- 
tal symptoms ought to be given more weight. 



140 Pregnancy. 



CHAPTER VII. 

THE PATHOLOGY OF PREGNANCY. 

Extra Uterine Pregnancy. — Pregnancy has few occurrences 
associated with it more disastrous in their results than the 
development of the ovum outside the uterine cavity. The fre- 
quency of laparotomy for the relief of pelvic hematocele has 
demonstrated the surprising frequency of this form of anoma- 
lous gestation. Veit w T as the first to find that at least twenty- 
eight per cent, of hematoceles result from extra-uterine preg- 
nancy, and Tait declares that all his cases have been traceable 
thereto. 

The spermatozoa having been deposited within the vulva, 
the vagina, or the cervical canal, make their way with variable 
rapidity through the uterine cavity and Fallopian tubes 
towards the ovaries. Fecundation, as has been stated, may 
occur at almost any point on the route, in the uterine cavity, 
in the Fallopian tubes, or at the ovaries; the most frequent 
point of contact between the male and female elements proba- 
bly being in the outer third of the tubes. After impregnation, 
the ovum may be arrested in its progress towards the uterine 
cavity, and development take place, at the ovary, in the 
abdominal cavity, or in the tube. Accordingly we have 
ovarian, abdominal and tubal pregnancy, besides some minor 
varieties, the designations indicating the situations of the 
developing ova. 

According to Bandl's statistics, extra-uterine pregnancy 
occurs only once in twelve thousand cases. Garrigues found 
two hundred cases recorded within four years. 

Ovarian Pregnancy. — Careful observers have put upon 
record several cases where fecundation and development of the 
ovum took place within the Graafian follicle. When this occurs, 
the follicle may close, and development go on outside the peri- 
toneal cavity, or the ovum may work its way through the 
aperture resulting from rupture of the follicle, and thus come 
eventually to lie chiefly within the peritoneal cavity. From the 
amount of distension to which the sac is subjected, rupture 
usually takes place within the early weeks of pregnancy, and 
the ovum enters the peritoneal cavity. Such an occurrence 
does not always prove fatal to ovular development, for the sac 



Ectopic Gestation. 



141 



walls are sometimes strengthened by adhesions to the perito- 
neum which covers adjacent viscera, and gestation goes on. 

False Ovarian, or Tubo-Ovarian, Pregnancy.— When the 
ovum is arrested in the fimbriated extremity of the tube, the 
cyst structure is composed partly of the fimbriae of the tube, 
and partly of ovarian tissue. This makes development less 
confined, and the pregnancy may continue, without rupture of 
the sac, to an advanced period, or even full term. This form 
much more nearly resembles abdominal than ovarian preg- 
nancy. When none of the investing structures are ovarian, it 
is termed tubo-abdominal. 




Fig. 98. — Abdominal Pregnancy. 

Abdominal Pregnancy. — The etiology of abdominal preg- 
nancy remains in doubt. It probably arises in some cases 
from the impregnated ovum being dropped directly into the 
peritoneal cavity, but in most instances very likely it is a 
secondary outgrowth from the tubal and ovarian forms. Dr. 
Barnes believes that it is never primarily abdominal, because of 
the difficulty of conceiving how so small a body as the ovum 
should be able to fix itself on the smooth surface of the perito- 
neum. The view is warmly supported by several close students 
of ectopic gestation. Some have supposed that abdominal 
pregnancy may originate from impregnation of an ovule 
already lying in the peritoneal cavity, by spermatozoa which 
have found their way thither. From all that has been observed, 
it is highly probable that it is no uncommon thing for an ovule 
to fall into the peritoneal cavity, and there, after an uncertain 



142 



Pregnancy. 



time, perish, without giving rise to any disturbance; but when, 
from fertilization, it does survive, a connective-tissue prolifera- 
tion is set up which invests the ovum with a vascular sac, 
thereby forming a decidua reflexa of peculiar construction. The 
latter often attains a thickness nearly as great as that of the 
uterine walls. The chorion villi sprout, form attachments to the 
sac and other structures, and eventually develop a placenta. 
The walls of the sac and the ovum generally develop pari passu,, 
and extend into the abdominal cavity, forming adhesions to 
the intestines, the mesentery, the omentum, the uterus and 
other structures. Occasionally the ovular development pro- 
ceeds without the formation of pseudo-membranes, the cover- 
ings of the foetus being only the amnion and chorion. 

Eupture of the foetal coverings usually takes place in extra- 
uterine pregnancy, and the foetus pass- 
es into the peritoneal cavity. Death 
of both embryo and mother generally 
follows, but, in other instances, the 
woman surviving, development is con- 
tinued by the formation of a new sac. 
When foetal death succeeds such an 
accident, the child may be converted 
into a lithopsedion, or the vascular 
connective tissue surrounding it may 
preserve the soft structures for years. 
The precise seat of attachment in 
abdominal pregnancy varies consider- 
ably. The placenta has been found 
fixed, at different times, to most of the 
abdominal viscera, to the iliac fossa 
and to the structures within the true pelvis. Its most frequent 
site is the recto-uterine space. 

Interstitial Pregnancy.— When development of the ovum 
takes place in the uterine portion of the tube, it is called "inter- 
stitial pregnancy." This portion of the tube is about seven 
lines in length. From hypertrophy of the muscular walls a sac 
is formed about the ovum, which projects from the involved 
angle of the uterus. Ovular development, however, is so much 
more rapid than the muscular, that rupture generally occurs 
before the fourth month. 

When the fecundated ovum is arrested near the outer boun- 
dary of the uterine part of the tube, as development proceeds 




Fig. 99. — A Lithopsedion. 



Ectopic Gestation. 



143 



the tumor escapes mainly into the tube, producing what has 
been called tubo-interstitial pregnancy. When development 
takes place on the borders of the uterine cavity, the resulting 
tumor may crowd through the Fallopian opening and lodge in 
the uterus, only to be finally expelled as in ordinary abortion. 
Diverticuli sometimes exist in the uterine wall, with small 
openings into the Fallopian tube, into which the impregnated 
ovum has been known to enter, and a peculiar kind of intersti- 
tial pregnancy result. 




Fig. 100. — Interstitial Pregnancy. 

Tubal Pregnancy.— This is the most frequent form of extra- 
uterine pregnancy, and properly comprises the forms described as 
"interstitial," "tubo-ovarian,' 1 and "tubo-abdominal." The 
cause of this anomaly is many times found in catarrhal affec- 
tions of the tubes, involving a loss of the ciliated epithelium 
which covers the mucous membrane, and doubtless more or 
less tumefaction, with consequent reduction of the calibre of 
the canal. In other cases the ovum is arrested in its progress 
by flexions and constrictions, resulting from adhesions and 
inflammatory bands. In rare instances it is due to the exist- 
ence of small polypi. 

In a number of surprising cases the corpus luteum has been 



144 



Pregnancy. 



found in the ovary upon the opposite side from that suffering 
from the abnormal development, showing that the ovum must 
have migrated from one side to the other, or that its vitality 
under certain conditions is preserved for a longer period than 
is generally supposed. 

After arrest, the chorion soon begins to develop villi, which 
engraft themselves into the mucous membrane of the tube, and 
serve as anchors to the ovum, and channels for supply of its 
necessary nutriment. The mucous membrane becomes hyper- 
trophied, very much like that of the uterine cavity in normal 
pregnancy, so that a sort of pseudo-decidua results. The 




Fig. 101. — Tubal Pregnancy. 

peculiar characters of the mucous lining of the tube afford for 
the ovum but a feeble hold, and hence hemorrhage, from 
separation of villi, is easily brought on. If early rupture does 
not take place, a spurious placenta may develop, which 
resembles the normal placenta in some particulars, and the 
rudimentary villi of which are sometimes surrounded by 
maternal vessels of some size. The muscular coat of the tube 
soon becomes hypertrophied, and, as the size of the ovum 
increases, the fibers are separated so that the ovum protrudes 
between them at certain points, and is there covered by the 
stretched and attenuated mucous and peritoneal coats of the 
tube. 

Rupture of the attenuated walls of the tube occurs most fre- 
quently during the fourth month, and the foetus is cast into 



Ectopic Gestation. 



145 



the peritoneal cavity. The attachments to the tube are so frail 
that the ovum has been known to escape unbroken, while again 
the tube has given way, but the ovum has pushed but partly 
through the opening. Death usually follows rupture, either 
immediately from acute internal hemorrhage, or secondarily 
from peritonitis. 

When maternal death does not speedily ensue after rupture, 
false membranes are often formed about the foetus, or the en- 
tire ovum, and it thus becomes encysted. 

The tube may rupture at a point where it is not covered by 




Fig. 102— Tubal Pregnancy. 

peritoneum, in which case there is escape of the ovum and 
effusion of blood between the folds of the broad ligament. This 
form, first described byDezeimeris,is known as extra-peritoneal 
pregnancy. 

In extremely rare instances, tubal pregnancy, owing to 
excessive thickness of the muscular walls, goes on to full term. 

Pregnancy in a rudimentary Horn of the Uterus.— This 
variety of ectopic pregnancy is probablj^ not so rare as has 
been generally supposed ; but since it cannot be differentiated 
from tubal pregnancy during life, and inasmuch as it subjects 
the woman to about the same dangers, it deserves in a work 
of this scope no extended consideration. 

(10) 



146 



Pregnancy. 



Rarer Varieties.— Among the rarer varieties is that in 
which the placenta is in a normal situation within the uterine 
cavity, and the foetus within the Fallopian tube. In another 
form the foetus is found in the abdominal cavity, and the pla- 
centa in the uterus, the two being connected by an umbilical 
cord running through the oviduct. The latter variety of cases 
has been called the utero-tubo-abdominal. Another rare form 
is known as the sub-peritoneo-pelvic, in which the ovum, from 
failure or inability to get within the tube, slips between the 
folds of the broad ligament, and there develops. 




Fig. 103. — Pregnancy in rudimentary Horn of the Uterus, a, developed 
horn, h, rudimentary horn, g, rupture. /, right ovary, o, left ovary. rn f 
peritoneal limit. 

Uterine Changes in Extra-uterine Pregnancy. — During the 
development of the foetus outside the uterus, changes, more or 
less marked, have been observed in that organ. They are sub- 
stantially those accompanying normal pregnancy in its early 
weeks, and consist chiefly in increased vascularhy, in marked 
increase in size, and in the characteristic thickening and hyper- 
trophy of the mucous membrane. 

A true decidua is formed quite like that of early pregnancy, 
which is subsequently cast off, though sometimes in fragments. 

The cervix softens slightly, but the internal os does not 
yield. These symptoms are of limited development, since the 
stimulus essential to their continuance, such as is supplied by 



Ectopic Gestation. 147 

entrance and implantation of the fecundated ovum, is wanting. 
Its bulk and vascularity are soon restored to nearly the normal 
standard. 

The uterus is more or less displaced by the extra-uterine 
growth, so that the cervix, instead of being found far back in 
the pelvis, as it commonly is in normal pregnancy, is pushed 
forwards. Still the uterus is more elevated than in the early 
weeks of a normal pregnancy. 

Symptoms of Extra-uterine Pregnancy. — In the early 
part of such a state there are few, if any, symptoms which 
differ materially from those attending normal pregnancy. The 
woman may enjoy health, unsettled only by gastric disturb- 
ances so common in gestation. Menstruation is interrupted in 
only about fifty per cent, of the cases, though it is finally sup- 
pressed in most instances, where the condition is not brought 
to a close by rupture of the sac. There is usually an irregular 
sanguinolent discharge, which may take the place of regular 
menstruation. The woman commonly complains of severe 
abdominal pain, mostly constant, but sometimes intermittent, 
within a circumscribed area. This pain is more likely to 
accompany the discharges just mentioned. Often previous to 
rupture, in addition to other sufferings, the woman experiences 
uterine pain of a bearing character. In other cases there is 
very little to attract attention to the case until the moment of 
rupture. When rupture does not occur, as the ovum increases 
in size, some discomfort may arise from pressure exerted by the 
tumor against other structures. Changes in the breasts and 
morning sickness are of common occurrence. After a time the 
enlargement attains greater size, resembling the gravid uterus, 
but situated a little to one side of the median line. Quickening 
and the foetal heart-sounds are soon discovered. 

Termination. — M. Dezeimeris, who has written a memoir on 
this subject, states that rupture takes place in more than three- 
fourths of all cases. In tubo-uterine pregnancy, it occurs, in the 
main, before the close of the second month ; in tubal, in the 
fourth month; in ovarian pregnancy, later, and in abdominal 
pregnancy, it may continue for an indefinite period. The most 
common termination then, by far, is rupture — rupture of the 
foetal membranes alone in abdominal pregnancy, and of both 
sac and membranes in other forms. 

The duration of the different varieties of extra-uterine preg- 
nancy is shown by the following tables, taken from Charpentier. 



148 Pregnancy. 

In nineteen cases of interstitial pregnancy, 

Gestation lasted 4 weeks in one case. 

" " about 3 months in 2 cases. 

" 3 months in 12 cases. 
" 4 months in 3 cases. 
14 5 months in 1 case. 
In eighty-eight cases of tubal pregnancy, 

Gestation lasted 4 to 5 weeks in 3 cases. 
" 4 to 6 weeks in 17 cases. 
" 6 to 7 weeks in 9 cases. 
" 6 to 8 weeks in 13 cases. 
" 2 months in 4 cases. 
" 3 months in 17 cases. 
" 4 months in 11 cases. 
" 5 months in 4 cases. 
" 6 months in 2 cases. 
" 7 months in 2 cases. 
" 9 months in 6 cases. 

In thirty-nine cases of ovarian pregnancy, 

Gestation lasted 3 to 8 weeks in 5 cases. 

" 2 months in 4 cases. 

" 3 months in 8 cases. 

" 4 months in 7 cases. 

" 5 months in 3 cases. 

" 6 months in 5 cases. 

" 7 months in 3 cases. 

" 9 months in 4 cases. 

Rupture is often preceded by the bearing pains alluded to, 
which may continue for hours. These suddenly cease; the tumor 
diminishes in size ; and then follow yawning, languor, fainting, 
clammy perspiration, rapid pulse, vomiting, collapse, and 
occasionally acute mania. These symptoms are succeeded by 
death, or, the bleeding being arrested, the woman rallies and 
escapes immediate danger. Still, death may follow at an 
interval of some days, purely as the result of hemorrhage. A 
moderate proportion of cases survive these perils, and the 
foetus remains, perhaps for years, without bringing about fatal 
results. 

When foetal death spontaneously occurs or is brought about 
by artificial means previous to rupture, the ovum in the early 
weeks will be almost wholly removed by absorption, while at a 
later period it may undergo a degenerative process by means 
of which it is converted into a mole, or a lithopsedion. Inflam- 
matory action may ensue, followed by suppuration, with 



Ectopic Gestation. 149 

ulceration into the hollow viscera or the peritoneal cavity. 
The immediate dangers of rupture are succeeded by others 
equally grave. As a result of rupture, severe peritoneal inflam- 
mation follows. Should the natural powers withstand this 
forcible onset, the results of the inflammation may be accounted 
favorable, inasmuch as pseudo-membranes are formed from 
coagulable lymph, which exercise a conservative influence by 
shutting off the ovum from the peritoneal cavity. In case 
rupture is not followed by peritonitis, and embryonic life is 
preserved, as development proceeds the movements of the foetus 
within its membranes often give rise to most intense suffering. 
In a certain proportion of cases, the foetus dies early , a suppura- 
tive inflammation in the sac is set up, and death results from 
general peritonitis, or from profuse suppuration. Should the 
woman survive, in consequence of low intensity and meagre 
extent of the action, fistulous openings to other hollow viscera 
may be formed, through which the sac contents will gradually 
be eliminated. Such an opening is extremely liable to make its 
way into the large intestine, sometimes through the abdominal 
walls, and rarely into the vagina or the bladder. At best, 
the process of elimination is extremely slow. For weeks or 
months, portions of the more indestructible foetal structures, 
such as bones and teeth, are discharged. During this discharge 
of debris the inflammatory action in the cyst goes on, and is 
probably intensified by the admission of air, or the contents of 
the viscera with which the sac communicates. Irritative fever 
supervenes, and death from exhaustion or blood poisoning is a 
common result. 

"If pregnancy goes on without accident or hindrance till the 
close of the period which ordinarily marks utero-gestation, 
pains come on, which are periodic, and which are described by 
women who have undergone normal labor as precisely similar 
to those attending that progress. 'These pains/ says Burns, 
' usually begin in the sac, and then the uterus is excited to con- 
tract and discharge any fluid it contains. ' This uterine effort 
at the close of the ninth month is a physiological fact of sur- 
passing interest." 

Diagnosis. — In the diagnosis of extra-uterine pregnancy, 
there are three points to be established : 1. The existence of 
the common signs of pregnancy; 2. The emptiness of the 
uterine cavity; and 3. The presence of a tumor in close conti- 
guity to the uterus. Diagnosis is attended with much difficulty, 



150 Pregnancy. 

and the best practitioners have been deceived ; and yet expert 
gynecologists and obstetricians now make few mistakes. 

The diagnosis of ectopic pregnancy, especially of the tubal 
variety, is a matter of great and increasing importance, since 
modern surgery has made it possible, in a constantly increasing 
ratio of cases, to avert the otherwise almost certain death 
which awaits the patient. But the symptoms are obscure, and 
in only a small percentage of cases are suspicions aroused 
concerning the normal character of the pregnancy, till rupture 
suddenly occurs. The existence of an irregular hemorrhagic 
discharge, appearing after the eighth week, is of some signifi- 
cance; also the paroxysmal cramp-like pains, radiating from the 
iliac fossa, which are often attributed by the woman to flatulent 
distension of the intestines, and thus escape critical notice. If 
then we meet a case presenting the signs of early pregnancy, in 
which the foregoing symptoms are superadded, our suspicions 
would justify a demand for a careful examination, when the real 
nature of the case may be discovered. 

A vaginal examination made at such a time would reveal 
the uterus somewhat enlarged, its cervix slightly softened, and 
the existence of a para-uterine tumor. When situated low, the 
use of conjoint manipulation will enable one to make out the 
form, and feel the fluctuation of the sac. In the absence of 
peritoneal adhesions, ballottement of the entire tumor can 
sometimes successfully be practiced. BaUottement of the foetus 
is practicable by the end of the fourth month. There are 
various conditions which give rise to physical signs of a 
similar kind, such as small ovarian and fibroid tumors, or even 
hematocele, and hence the difficulty of differential diagnosis.* 

The development of symptoms which point to possible extra- 
uterine pregnancy in a woman after long cessation of fruitful- 
ness, is peculiarly suggestive. 

Dr. E. H. Grandin has contributed an important considera- 
tion with respect to the diagnosis of advanced ectopic gesta- 
tion, namely, the absence of Hick's valuable sign of normal 
gravidity,— intermittent uterine contractions. 

In view of the desirability of early recognition of extra- 
uterine pregnancy, it is justifiable, when the other evidence in 



*A curious example of the difficulties of diagnosis is recorded by Joulin, in which 
Huguier, and six or seven of the most skilled obstetricians of Paris, agreed on the exist- 
ence of extra-uterine pregnancy, and had, in consultation, sanctioned an operation, when 
the case terminated by abortion, and proved to be a natural pregnancy. 



Ectopic Gestation. 151 

favor of the condition is strong, to pass the uterine sound to 
demonstrate the absence of intra-uterine development. 

When rupture of the sac occurs early in pregnancy, the 
flow of blood may be moderate, and the physical signs only 
those of ordinary hematocele. Later rupture gives rise to 
symptoms of extensive internal hemorrhage, and presents a 
ghastly percentage of deaths. 

In abdominal pregnancy the form of the abdomen will be 
observed to differ from that of normal gestation, enlargement 
being more in the transverse direction. In the latter months 
the form of the foetus can be felt with remarkable distinct- 
ness. The cervix is somewhat softened, but often displaced, 
and sometimes fixed by perimetritic adhesions. Conjoint touch 
may enable the examiner separately to distinguish the uterus 
from the bulk of the tumor, and demonstrate its nearly normal 
non-pregnant size. 

When extra-uterine pregnancy goes beyond the fourth 
month without occurrence of rupture, whether originally tubal 
or not, with rare exceptions, either an ovarian or abdominal 
pregnancy should be assumed to exist. 

As a final mode of examination in doubtful cases, the woman 
should be anaesthetized, and deep and thorough bimanual 
manipulation resorted to. Under such conditions the finger 
will be passed into the uterine cavity, into the rectum or into 
the bladder, the risk being assumed by the physician, of its 
proving to be a case of uterine pregnancy with consequent 
miscarriage. 

Treatment.— The mode of treatment will be determined 
largely by the degree of development which has been attained, 
the condition of the foetus, and the health of the woman. For 
the sake of perspicuity and convenience, we make three classes 
of cases, namely: 1. Those which have not advanced beyond the 
limits of a few weeks; 2. Those wherein gestation is well 
advanced, and the foetus is still living; 3. Those in which 
pregnancy has been prolonged after foetal death. 

1. Cases of Eecent Impregnation. — It has been observed 
that, when from any cause embryonic life is destroyed, recovery 
often ensues. Following this hint, it has been proposed as a 
mode of treatment to adopt measures which will compass such 
a result. This has been done in some cases with good results, 
the methods employed being puncture of the sac, injections of 
morphia and other solutions, and the electric current. 



152 Pregnancy. 

Destruction of foetal life is advisable below the age of four 
months, up to which time nature is probably capable of 
absorbing the product of conception, or at least rendering it 
harmless; but when greater age has been attained such a 
result can scarcely be expected, though Dr. Ely Van de Walker 
reports a case in which a five-months foetus was absorbed 
within three weeks after having been killed by electricity. 

Puncture of the sac, as recommended by Scanzoni, is 
generally effected by introducing an exploring needle, a trocar 
or an aspirator needle, through either the vaginal or rectal 
wall, and drawing off the liquor amnii. The results of this 
mode of treatment have not been wholly satisfactory, and 
fatal effects have several times been produced. In most of the 
cases, if not in all of them, however, an ordinary trocar was 
employed, which necessarily admitted air. We can hardly 
believe that a small aspirator needle used with antiseptic 
precaution, could produce serious results. Numerous instances 
of recovery have been put on record. 

Injections into the Sac. — Joulin was the originator of this 
method, and he proposed injections of sulphate of atropia. 
Friedrich afterward followed the suggestion with success ; but 
morphia was subsequently employed by him with more satis- 
factory results. Koeberle was also successful with injections. 
The site of puncture is the abdominal or the vaginal walls. 
When the needle has once entered the sac, a few drops of the 
liquor amnii are withdrawn and their place supplied by the 
solution of morphia. The operation should be repeated every 
second day, until evidences of success are discernible. 

Electricity.— To Paul Dubois is due the honor of originating 
the treatment of early ectopic pregnancy by means of elec- 
tricity. It was first employed in this country by Dr. Joshua G. 
Allen in 1869, and within a few years it has become essentially 
the American method. 

Out of ninety-seven cases of extra-uterine pregnancy reported 
during the last three years, twenty were treated by electricity, 
with only two deaths, and those not justly attributable directly 
to the treatment. 

The operation consists in passing the electric current through 
the ovum, and thereby destroying its vitality. The faradic 
current is the one commonly used, the full strength of one cell 
continued for a few minutes, at intervals of twenty-four hours, 
for several days, will accomplish the purpose. One pole of the 



Ectopic Gestation. 153 

battery should be placed in the rectum, against the tumor, 
and the other upon the abdomen directly over it, so as to bring 
them as near the ovum as possible. 

Evidence of embryonic death is found in diminished tension, 
and, ultimately, in shrinkage of the cyst. 

This form of treatment ought not to be adopted in preg- 
nancy which has exceeded four months. 

Laparotomy. — Tate, Martin, Edis, Jarvin and others ad- 
vocate this operation instead of attempts at embryonic destruc- 
tion, and show excellent results. Still we decidedly favor the 
distinctively American operation by electricity , believing it best 
conserves the patient's interests, though less radical and bril- 
liant. 

Treatment After Rupture. — When rupture of the sac takes 
place, treatment should have for its primary object arrest of 
internal hemorrhage, and removal of the effects of shock. If the 
vital forces of the woman are not too low, an ice-bag may be 
applied to the abdomen. Very hot applications will answer 
better in case great depression exists. Compression of the 
aorta, and a sand-bag upon the abdomen over the site of the 
ovum, have also been recommended. The patient should be 
placed in a cool, quiet place, stimulants in small quantities ad- 
ministered as often as required, and, in the absence of other 
special indications, china given. It will be well to follow with 
several doses of aconite, in anticipation of the peritoneal in 
flammation which is so likely to ensue. 

Twenty-two years ago, Dr. Stephen Rogers, of New York city, 
recommended laparotomy for the control of hemorrhage caused 
by rupture of the sac in extra-uterine pregnancy. Some time 
afterwards, Yeit, of Berlin, performed it. In January, 1883, 
Lawson Tait operated under these circumstances, and during 
that and the succeeding year he added four cases. The lives of 
four out of these five women were saved. Dr. Charles K. Brid- 
don operated in October 1883, and has subsequently done so a 
number of times. During the past few years Tait has operated 
on about twoscore cases, with almost uniform success. In view 
of the recent great improvements in abdominal surgery, it has 
come to be the duty of the obstetric surgeon thus to deal with 
these cases which formerly resulted so disastrously. 

There is some question concerning the proper time for opera- 
tive interference. In most of Tait's cases the operation was 
performed some hours after the development of symptoms indi- 



154 Pregnancy. 

eating rupture of the sac. The condition immediately following 
rupture is essentially one of collapse, and therefore one de- 
cidedly inimical to a serious operation like the one in question. 
It follows, then, that the first indication is to control hem- 
orrhage by indirect means, if possible, and excite reaction, as 
hereinbefore stated. If such efforts prove unavailing, long 
delay would be inadvisable. 

The operation consists in the usual abdominal incision, con- 
trol of the hemorrhage, if it still continues, by ligature or com- 
pression, and in removal of the debris. The peritoneal cavity 
should be carefully washed out and the abdominal wall closed 
in due form. Something more than this is occasionally re- 
quired. In case of interstitial pregnancy, oozing may continue 
in spite of every expedient, and hysterectomy be required. In 
other cases it may be necessary to remove the uterine appen- 
dages upon the side involved. 

2. Cases of Advanced Gestation, the Fcetus Stile Liv- 
ing.— Most women suffer during the progress of such an 
abnormal gestation from attacks of circumscribed peritonitis, 
from great sensitiveness to foetal movements, from recurring 
uterine hemorrhages, from emaciation and from depression of 
the vital powers. With the occurrence of labor-like efforts, 
peritonitis is apt to be relighted. Considering all the dangers 
to which both woman and child are exposed under the ex- 
pectant plan of treatment, it has been proposed that an early 
operation be performed, with a view to rescuing the latter from 
certain death, without materially increasing the risks sustained 
by the former. But the results of such operations have been of 
a disheartening nature, the chief source of danger being found 
in the hemorrhage which necessarily follows removal of the 
placenta. On the other hand, when the placenta is permitted 
to remain, septic poisoning and fatal hemorrhage are liable to 
occur during the process of elimination. The difficulties are 
made still more formidable by the situation of the placenta, in 
a considerable percentage of cases, on the line of incision. The 
operation has been performed but a few times in this country. 

Operation through the Vagina.— From thirty-three cases 
Dr. Herman draws the following conclusions: 1. The operation of 
opening an extra-uterine gestation sac by the vagina early in 
pregnancy, before rupture has taken place, by the cautery, 
knife, or otherwise, is a dangerous proceeding. Abdominal sec- 
tion ought always to be preferred. 2. Soon after rupture has 



Ectopic Gestation. 155 

taken place, when interference is called for to arrest hemorrhage, 
abdominal section is more likeh 7 to succeed than vaginal. 3. 
When rupture has taken place, and the effusion of blood is fol- 
lowed by pyrexia, the indications for incision of vagina are the 
same as those in hematocele from any other cause. 4. At, or 
soon after, full term, before suppuration has taken place, there 
may be conditions which indicate delivery by the vagina as 
preferable to abdominal section. These are, 5, when the foetus 
is presenting by the head, breech, or feet, so that it can be ex- 
tracted without altering its position, and, 6, when it is quite 
certain, from the thinness of the structures separating the pre- 
senting part from the vaginal canal, that the placenta is not 
implanted on this part of the sac, and it is not certain that the 
placenta is not implanted on the anterior abdominal wall. 7. 
If the child cannot be delivered by the vagina without being 
turned, abdominal section should be performed. 8. No attempt 
should be made to remove the placenta. 9. The after-treat- 
ment should consist in frequent washing out of the sac. 10. 
After suppuration has taken place, the spontaneous opening of 
the sac into the vagina is one of its more favorable termina- 
tions. 

3. Cases of Gestation Prolonged after Death of the 
F(etus. — When the foetus is dead, no attempt should be made to 
remove the product of conception during the existence of labor 
pains, as the dangers would be thereby unnecessarily enhanced. 
It is generally thought advisable to wait, carefully watching 
the patient, until the symptoms become grave, or there is posi- 
tive indication of the channel through which elimination of the 
foetus is about to take place. If relief is to be found through 
the vagina, it will be shown by bulging of the cyst in or about 
this organ. An opening may be effected by the natural efforts ; 
in which case it ought to be artificially enlarged to a size 
which will admit of foetal exit. Should the opening be into the 
intestines, the dangers and difficulties attendant on expulsion 
become so great that laparotomy would be justifiable. 

It is obvious that the presence of a dead foetus seriously com- 
promises the safety of the woman, and the suppurative process 
which is liable to ensue, inevitably reduces her to a deplorable 
condition. In view, then, of the success which has attended 
secondary laparotomy, on one hand, and the extreme dangers 
of waiting, on the other, operative interference seems to be a jus- 
tifiable procedure. Out of thirty -three cases collected by Litz- 



156 Pregnancy. 

mann, twenty-four of which were between 1870 and 1880, there 
were nineteen recoveries. It will be observed that the two great 
dangers which attend the primary operation (that made during 
foetal life) — hemorrhage and septicaemia — are in this operation 
greatly modified, the former by gradual thrombosis and oblit- 
eration of the maternal vessels which follow cessation of the 
foetal circulation, and the latter by the possibility here afforded 
for the removal of the entire ovum, or the speedy subsequent 
separation and extraction of the placenta. 

The following figures, furnished by Deschamps, showing the 
common termination of cases left to nature, and the results of 
interference, are among the most recent : 

In 11 cases formation of lithopaedion or encystment. 
" 19 cases opening into rectum with 8 deaths. 
" 3 cases " into vagina " 1 death. 
" 1 case " into uterus " 1 death. 

" 5 cases " at umbilicus " death. 
" 18 cases secondary laparotomy " 4 deaths. 

With respect to the time for the performance of secondary 
laparotomy, a clear notion is of much importance. The time 
of foetal death should be carefully noted, and our object should 
be to delay a sufficient length of time to provide for oblitera- 
tion of the placental vessels. Schroeder removed the placenta 
without loss of blood three weeks after cessation of foetal move- 
ments. De Paul operated four months after foetal death, and 
lost his patient from placental hemorrhage. There is no doubt 
that the process of obliteration of the placental vessels is rap- 
idly effected in some, and slowly in others ; hence, under the cir- 
cumstances, unless interference be urgently demanded, it is 
advisable to postpone operative measures, and treat the patient 
symptom atically. 

The woman should receive an abundance of fresh air and 
nourishing food, while in the absence of more specific indica- 
tions arsenicum ought to be administered. Should marked 
septic symptoms be developed, they ought to be regarded as a 
signal for interference, since delay would almost certainly be fatal. 

The operation itself should begin with an incision along the 
linea alba, as in other cases. If no adhesions are found between 
the cyst and surrounding structures, the former can be turned 
out through the incision, before rupture, and stitched to the 
cut borders of the abdominal wall. The placenta, unless it 
occupies the site of the incision, or unless it separates at once 



Missed Labor. 157 

spontaneously, should be permitted to remain. The cord 
should be placed in the lower part of the wound, which will be 
left open for its reception and for drainage. 

Missed Labor. — "An extremely rare and curious phenome- 
non has been occasionally observed, in which, the foetus remain- 
ing in utero, labor has not come on at the usual time, and the 
remains of the foetus may be retained for a considerable period, 
or discharged piecemeal by the vagina, without, for a time at 
least, seriously affecting the health of the mother." This has 
been called "missed labor." 

Muller, after investigating forty-five cases of alleged missed 
labor, concluded that there does not exist an authentic obser- 
vation of retention of the foetus within the womb beyond the 
term of ordinary pregnancy. By many they are regarded as 
instances of extra-uterine pregnancy. 

For the most part, death of the foetus is followed either by 
premature expulsion, very soon after life is extinct, or by the 
occurrence of abnormal development of the foetal envelopes, 
and a perversion of the natural energies, culminating in molar 
pregnancy. In the rare cases above alluded to, neither of these 
occurrences is observed, but the foetus becomes mummified, or 
disintegrated, and its remains are retained in utero for months, 
or even years. The cause of this is supposed to be absence of 
uterine irritability, obstructed labor, and unusually close adhe- 
sions of the placenta. In many cases uterine expulsive action 
is set up, but, after a time, it ceases permanently, or is renewed 
at intervals, for days, weeks, or even months. Whenever the 
ovum perishes and is kept in the womb for a time far in excess 
of the period of normal utero-gestation, whether molar changes 
take place, the foetus is disintegrated and discharged piecemeal, 
or becomes mummified; indeed, whether any decided post- 
mortem changes take place or not, they constitute an instance 
of what has been known as "missed labor." Manget reports an 
observation by Langelott of a case in which the foetus perished 
in the fifth month, and was not expelled until the twelfth 
month, in a mummified condition. Johns observed two cases 
in which the foetuses died at the sixth month, and were not born 
till five and six months respectively after their death. Olshausen 
reports a case of retention of a mummified three-months foetus 
for eight-and-a-half months. McMahon relates a case in which 
a foetus of four months was retained for eighteen months, and 
was then expelled, inclosed in a compressed placenta which 



158 Pregnancy. 

evidently had continued growing for some time after foetal 
death. The calcified or mummified fetus is said to have been 
retained many years. Foetal bones have been discharged from 
the uterus where they had been incrusted for years. 

Dr. Stanley P. Warren relates a case of missed labor result- 
ing from rigidity of the os uteri in which delivery was finally 
effected through Csesarean section. 

A. Halley and H. Davis report the case of a woman who, in 
the second half of her pregnancy, had a brownish discharge 
from the vagina, and occasionally lost putrid fleshy masses, 
at times accompanied with bones. Four years later the os 
uteri was artificially dilated, and eighty-six bones removed in 
two sittings. In rare cases of prolonged retention, the foetus 
becomes the seat of fatty and calcareous degeneration, in which 
case it is designated by the term u lithopa?dion." The subject 
of missed abortion is considered in another place. 

Treatment. — When a woman has presented undoubted signs 
of pregnancy, has passed by the period of mature gestation , and 
evinces indications of foetal death, followed by disintegration 
or mummification, it is clear that something ought to be done 
to effectually rid the system of the depressing influences to 
which it is subjected. This can be done only by securing thor- 
ough uterine evacuation. 

We should begin by seeking a remedy which covers the 
symptoms. It will probably be found among the antipsorics, 
and is likely to be sulphur, calcarea carb., silicia, or Arsenicum. 
If the carefully chosen remedies fail, we may afford relief by 
mechanical and manual means, but it should not be undertaken 
unless the condition is seriously disturbing the health. But if 
active interference be required, the lower numbers of a set of 
graduated steel dilators may at first be used, and when suffi- 
cient dilatation has been secured to admit of its easy introduction 
we may employ Allen's dilator, and finally a Barnes' bag, fur- 
ther to expand the os. When it has thus been opened, the oper- 
ator should proceed much as he would in abortion, rely- 
ing mainly on the placenta forceps or small blunt hook, and 
finally the curette, as a means of complete delivery. If putrid 
masses be taken away, the uterus, after complete evacuation, 
should be washed out with a mild antiseptic solution. This 
operation, like all others, ought to be performed throughout 
under antiseptic precautions, and followed with a few doses of 
arnica. 



Premature Expulsion. 159 



CHAPTER VIII. 

PREMATURE EXPULSION OF THE OVUM. 

Premature expulsion of the product of conception may take 
place at any moment prior to the time when the foetus presents 
all the evidences of maturity, and the process has received dif- 
ferent designations according to the stage of pregnancy at 
which it occurs. Interruption of pregnancy during the first 
three lunar months is termed abortion; during the fourth, 
fifth, sixth and seventh months, that is, from the time when 
the placenta is fully formed to the date of viability, it is called 
miscarriage; and from that time to the close of the thirty- 
eighth week it is known as premature labor. While these are 
the technical distinctions, the terms abortion and miscarriage 
are used interchangeably by many, and, as we believe, with 
perfect propriety. 

The term foetus, according to usage, is not applicable to 
the product of conception until the termination of the third 
month of gestation. Till then it is known as the embryo. 

The liability to premature expulsion is doubtless greater in 
the early weeks of gestation, w T hen the union between the cho- 
rion and decidua is imperfect, as hemorrhage is apt to occur and 
fill the space between them, thereby cutting off communication 
between the mother and child. 

Obstetrical writers do not agree as to the relative frequency 
of abortion. Hegar reckoned one abortion to every eight or 
ten full-time deliveries, while Devilliers sets them down in the 
proportion of one to three or four. The statistics of Whitehead 
show T a proportion of about one to seven. Probably thirty- 
seven out of every hundred mothers experience abortion before 
they attain the age of thirty years. 

Causes of Abortion. — The causes of abortion, miscarriage 
and premature labor, are, in the main, of slow, but cumulative 
action. The uterus is a patient organ. It will bear a good 
deal of abuse, neglect and interference, and with the greatest 
reluctance does it finally exhibit resentment. It is the mother 
organ, and in the quiet forbearance and self-sacrificing 
devotion to the new 7 being which it nourishes, it is a reflection 
of the maternal mind. Evil influences set themselves at work 
and gradually undermine the vitality of the ovular structures 



160 Pregnancy. 

and render insecure the placental attachments to a degree 
which finally enables a very little accident to precipitate 
expulsion. 

As long as there is life in the inchoate being so carefully 
wrapped up in the membranes, the uterus holds on with sur- 
prising tenacity; but when that is from any cause extinguished, 
the enveloping organ begins to gather force with which to effect 
its expulsion. These are the phenomena most commonly ob- 
served; but in a certain percentage of cases, the uterus is 
excited to expulsive effort before foetal death occurs. 

Predisposing Causes.— Death of the foetus is sometimes the 
result of direct or indirect violence; but it is oftener due to slow 
pathological changes in the embryonic or the maternal struc- 
tures directly concerned in nutrition. 

When death overtakes the embryo or foetus, it at once 
becomes a foreign body, and with conservative sense the womb 
sets at work to bring about complete evacuation. The villi of 
the chorion in early pregnancy, and of the placenta at a later 
period, undergo atrophy and fatty degeneration, and when the 
ovum is thus loosened from its moorings, uterine contractions 
are set up and expulsion is accomplished. 

A small embryo, if long retained, may become disintegrated 
in the amniotic fluid, and thus disappear. 

In early abortion the sac frequently comes away intact ; but 
at a later period it rarely does. 

Ovulary Causes. — These include the various diseases and 
accidents affecting the foetus and its envelopes, details of which 
need not here be given. 

Maternal Causes. — Abortion often finds its predisposing 
causes in morbid conditions of the deciduse. Among these are 
(1) atrophy, and (2) hypertrophy of the uterine mucous 
membrane. 

The endometrium, instead of affording a generous reception 
to the impregnated ovum, and snugly enclosing it, in some 
cases spreads an abnormally thin decidua, with the result, a 
small placenta. In other cases the decidua reflexa is not com- 
pleted, or may utterly fail of development; in which case, 
covered only by the chorion, the ovum is suspended from the 
serotina. 

In either case, the ovum, instead of being at once expelled 
by the uterine contractions, may be forced downwards to the 
cervix, and there remain for a time nourished by the pedicle 



Premature Expulsion. 



161 



which it forms. This has received the name of cervical preg- 
nancy. It is chiefly the rigidity of the os internum and the 
cervix which retains the ovum, and hence it is an occurrence 
more common in primiparse than in multiparae. In some 
instances, however, the strength of the pedicle is sufficient to 
prevent further descent, even when the os is patulous. 

Endometritis with consequent thickening of the mucous 
membrane is a frequent cause of abortion, from the fact that it 
gives rise to structural changes in the placenta. A placenta 
thus involved may fail to supply to the fetus requisite nourish- 
ment, or the weakened vessels of the decidua may rupture and 
produce sanguineous effusion between the membranes. 

In retroversion, which is recognized as a common cause of 
abortion, the endometritis is probably the chief factor in 
bringing about the untoward result. 

Interstitial and submu- 



«MtK9ttti 



m^ 




mnmns? 



cous fibroids, by preventing 
equable development of the 
uterine walls, and by en- 
croaching on the uterine 
cavity, may be the means 
of exciting expulsive action. 

The results of former cel- 
lular or peritoneal inflam- 
mation may prove seriously 
inimical to continued ges- 
tation, through the irrita- 
tion caused by adhesive 
bands and thickened para- 
uterine structures. 

It is customary to place 
syphilis at the head of causes 
of premature foetal death, and after it follow pernicious anaemia, 
chronic metritis, and endometritis. Dr. Fehling has shown 
that this result very frequently results from kidney dis- 
eases of the pregnant woman. In all the cases referred to, 
albuminuria occurred, partly as the result of parenchymatous 
nephritis and partly as the result of a genuine contraction of the 
kidneys. After death of the foetus the albuminuria increased 
rapidly. In the placenta may be observed deposits due to in- 
farction, so-called fibrinous wedges, the result of an ischemic 
necrosis. 
(ID 



Fig. 104. — Ovum with imperfectly 
developed Decidua Reflexa. 



162 Pregnancy. 

Acute diseases, especially those creating high temperatures, 
are liable to result in abortion. 

Napier lays emphasis on neuralgia as a predisposing cause. 
Following are his conclusions : 

1. Neuralgia and abortion are frequently associated. 

2. In certain cases of "habitual abortion/' neuralgia invari- 
ably manifests itself as the first symptom, attacking cranial or 
spinal nerves remote from the uterus. 

3. If treatment relieves the pain there is a strong probability 
that uterine disturbance will not commence, or, if already there 
have been contractions, these will cease. 

4. Neuralgia, while perhaps most common in the rheumatic, 
occurs in different types of patients : in the anaemic, dyspeptic, 
or malnourished ; or in the overfed, indolent and plethoric. 

5. Abortion sometimes evidently results from the reflex irri- 
tation associated with the neuralgic pain. 

6. Acute neuralgias occurring in pregnancy may not in any 
way interrupt healthy gestation. 

7. When severe facial, cervical, or other neuralgia yields to 
treatment, even though the embryo be dead, uterine contrac- 
tions and emptying will not occur for days, perhaps weeks. 

8. The trifacial, occipital, and cervical nerves are most com, 
monly affected ; but brachial, intercostal, lumbar, and sciatic 
neuralgias are also met with. 

9. Acute gastric irritation is associated with neuralgia 
and abortion. Pregnancy sickness, although very severe, 
seldom causes miscarriage; but gastrodynia, which is some- 
times accompanied by salivation and a constant feeling of 
nausea and depression, not infrequently precedes acute neu- 
ralgia, which eventually causes uterine irritation and ends in 
abortion. 

In many cases it is impossible to trace the cause of the oc- 
currence to any abnormal conditions of either the foetus and its 
envelopes, or the maternal generative organs. In such women 
there doubtless exists a condition of nerve irritability, which 
readily reflects irritation proceeding from physical or psychical 
sources, with force sufficient to produce powerful premature 
uterine action. 

Immediate Causes of Abortion. — The immediate causes of 
abortion arise in general from the maternal side. No changes 
on the part of the ovum, save those of forcible separation of 
the attachments, or rupture of the membranes, could bring 



Premature Expulsion. 163 

about the result. The maternal influence, however, is strong 
and unmistakable, and is often exerted, willingly or unwillingly, 
with the effect to interrupt pregnancy. 

Uterine Congestion. — Active or passive congestions of the 
uterus are probably the m ost frequent proximate causes of abor- 
tion. In those cases wherein influences have been silently at 
work to weaken the relations between the ovum and decidua, any 
circumstance which is capable of determining an unusual quan- 
tity of blood to the organ is capable of causing extravasation, 
separation, and premature expulsion. Hyperemia excited by 
an accomplishment of the menstrual cycle, fevers, inflammation 
of the genitalia, excesses in coitus, hot foot-baths, the use of 
certain drugs, unusual physical exertion, valvular heart-lesions, 
obstructions of the pulmonary or portal circulation, may be 
the means of precipitating expulsive action. Under conditions 
of uterine hyperemia, a very slight motion or jar, vomiting, 
coughing and straining, to say nothing of falls, injuries, and 
violent emotions, are capable of hastening the fall of the unripe 
fruit of the womb. 

The significance of pre-existing remote causes, associated 
with accidental occurrences, is clearly shown in many recorded 
cases. When the connections between decidua and ovum have 
not been weakened by the occurrence of any of the changes be- 
fore mentioned ; in other words, when the woman in all her 
generative tissues is in a healthy state, most powerful influences 
of a baneful nature are often suffered, without interruption of a 
normal course of gestation. Falls from considerable heights, 
giving rise to severe contusions and fractures, have repeatedly 
occurred to pregnant women without causing abortion. Dr. 
Pagan tells of an instance in which his coachman drove directly 
over a woman who was in the eighth month of pregnancy, in- 
flicting upon her serious injuries, and still gestation proceeded 
in a regular manner to term, and terminated in the birth of a 
healthy child. M. Gendrin speaks of a young lady who was 
thrown from a chaise over the horse's head, by the animal fall- 
ing in his career. The lady was then five months pregnant, but 
the accident did not prevent her from reaching her full term. 
Cazeaux met a case precisely similar in the wife of a notary liv- 
ing near Paris. Women, with a desire to rid themselves of a 
developing ovum, sometimes resort to most desperate measures 
without success. 
Matthews Duncan mentions a case wherein an intra-uterine 



164 Pregnancy. 

stem pessary was introduced and worn for some time during 
pregnancy, without exciting miscarriage. A woman seven 
months pregnant jumped from a third-story window to the 
pavement below without suffering abortion, though she broke 
both her legs and arms. Operations of all degrees of severity 
have been performed with immunity from the result in question . 
Limbs have been amputated, ovaries have been removed; the 
vaginal portion of the cervix uteri has been cut off, and sub- 
mucous fibroids have been taken away by laparotomy. 

Symptoms of Abortion.— Early abortion may, and doubt- 
less does, occur, in many cases, with symptoms differing but 
little from those attending a return of the monthly flow. There 
are pains in the sacral and hypogastric regions, and bearing 
sensations in the pelvis, with a rather free flow of blood, and 
then the whole ovum may be discharged, enveloped in a clot, 
thereby utterly escaping notice. In other cases the sac is 
ruptured by the uterine contractions, the embryo escapes 
unnoticed and the membranes soon follow. 

In either case there is generally but a moderate loss of 
blood ; but the rule is not without its exceptions. In a certain 
proportion of instances, even in the early weeks of pregnancy, 
the hemorrhage attendant on the occurrence is remarkably pro- 
fuse, and occasionally even alarming. Still the practitioner may 
comfort himself and patient with the reflection that in early 
abortion, under intelligent management, this symptom* is more 
alarming than dangerous, since women who are the subjects 
of it not only survive, but rarely suffer serious impairment of 
health or strength. 

As soon as the ovum, whether whole or in fragments, has 
been completely extruded, there is usually an end to the bleed- 
ing, and but a short period of time is consumed in uterine 
involution. But in early, as well as later, abortion, the presence 
in utero of any part of the product of conception, whether it be 
embryo or envelopes, is apt to continue the hemorrhage. There 
may be temporary cessation, but the flow again returns to de- 
clare that the abortive process is incomplete. 

Later abortions present more pronounced characters. The 
pains are more severe, the flow more profuse, and the effect on 
the woman more profound. For some time before these symp- 
toms set in, prodromata are generally experienced consisting of 
fullness and weight in the pelvis, sacral pains, frequent micturi- 
tion, and a mucus or watery discharge. These, followed" by 



Premature Expulsion. 165 

recurrent pains and hemorrhage, indicate a threatened abor- 
tion. There may be but a slight discharge at any time during 
the progress of the case, but in every instance there is liability 
to exhausting and even dangerous hemorrhage. The peril to 
life from the blood loss is not great, but the baneful effects of 
a sanguineous depletion, such as is now liable to be suffered, 
are not speedily remedied. The tenor of the woman's general 
health may be seriously impaired for months, or even years. 

In a typical case of abortion occurring about the third 
month, the ovum is extruded without rupture, in which case it 
passes into the vagina, with the embryo visible through the 
thin membranes, and the imperfectly formed placenta attached. 
The uterus, then being empty, contracts down, and the hemor- 
rhage is at an end. In abortions occurring after the third 
month, it is uncommon for the ovum to come away entire ; but 
the membranes are ruptured, the foetus expelled, and the secun- 
dines are retained. During the period of retention, which may 
be prolonged, the woman is in constant danger of profuse and 
sudden loss of blood. After the abortive act has been finished 
by complete evacuation of the uterus, hemorrhage is an unusual 
occurrence ; but in rare cases, owing to a depraved state of the 
system, to intra-uterine growths, or to imperfect involution, it 
becomes an annoying complication of the puerperal state. 

Incomplete Abortion.— Retained secundines, whether in 
early or later abortion, are apt to prove a source of much 
trouble. Here, as in labor at full term, after expulsion of the 
fetus the uterus is disposed to take a season of rest ; but, un- 
like the latter, this rest is usually prolonged. We may some- 
times vainly wait hours or days for renewed action, while 
cases are by no means rare in which vigorous uterine contrac- 
tions never return. 

The comparative comfort of the woman will lead her to 
believe that the process is complete, and a physician may not 
be consulted until serious symptoms are developed. Violent 
hemorrhage may at any time ensue, or in default of that, sep- 
ticaemia may be set up. In many cases the physician does not 
reach his patient until the foetus has been expelled, and the clots 
which generally follow are falsely assumed to be the afterbirth. 
The patient or friends being deceived by these, the physician is 
informed that everything has come away, and as all evidence 
has been destroyed, the confident statement of the attendants 
is liable to make him the dupe of credulity. 



166 Pregnancy. 

The Diagnosis of Incomplete Evacuation becomes a point of 
great nicety, in those cases where the extruded matters have all 
been preserved, as well as in those where they have not. When 
the ovum is discharged with its membranes intact, it is not 
difficult to arrive at a positive conclusion; but this does not 
always occur. The placenta, or decidual mass, is relatively large. 
The size of the embryo, at an early period, may be represented 
by the last phalanx of the little finger, or a Lima bean, while 
the afterbirth, when spread out, is as large as one-third of the 
hand. In some cases the secundines are expelled or extracted 
in fragments, and a retained portion is easily overlooked. It 
follows that absolute certainty can be attained only by careful 
exploration with the finger. 

Cases are on record in which the order of expulsion was re- 
versed. The membranes were rujjtured and expelled, uterine 
action ceased, and the foetus was retained. Dr. Noeggerath 
mentions a case in which the membranes were expelled at the 
fourth month of pregnancy, and the foetus w T as retained for 
several weeks. In the interval between the expulsion of the 
membranes and birth of the foetus, the woman was in a com- 
fortable state. Dr. Chamberlain relates a case in which the 
membranes were expelled, but the foetus continued in utero for 
twelve weeks. Dr. Peaslee had a similar case in which the 
foetus tarried three months. In the last two cases the women 
manifested symptoms of retention of a part of the ovum, there 
being hemorrhage and irritative fever. 

The following observations by Spiegelberg concerning in- 
complete abortion merit most attentive study : 

1. Most frequently hemorrhage continues at intervals, spon- 
taneous elimination gradually taking place, as through retro- 
grade changes, portions of the retained membranes become 
successively loosened from their attachments to the uterus. 

2. In exceptional cases the hemorrhage ceases for a time en- 
tirely. For days, weeks, and even months, the woman appears 
quite well, then suddenly strong contractions, accompanied by 
profuse hemorrhage, usher in the elimination of the foetal de- 
pendencies. 

Lusk says, in a case of his own, three months elapsed from 
the occurrence of the first hemorrhage, which took place towards 
the end of the third month, and was quite insignificant in 
amount, before the abortion was completed. Meanwhile, as 
there were progressive abdominal enlargement, supposed 



Premature Expulsion. 



167 



quickening, and milk in the breasts, the threatened abortion 
was believed to have been arrested. 

Total retention with a long interval of quiet is supposed to 
proceed from an unbroken relationship between the placenta 
and the uterine walls, by means of which the former, though 




Fig. 105. — Uterus, with basis of a Fibrinous Polypus after an abortion. 

(Frankel.) 

functionally inactive, continues to receive nutrient supplies from 
the uterus. The retained secundines, if not removed by arti- 
ficial means, have a strong impulse to come away at a men- 
strual period. 

3. Of more frequent occurrence than the foregoing, is the 
putrid decomposition of the retained portions. It occurs chiefly 
in cases where there is more or less complete loss of organic 



168 Pregnancy. 

connection between the placenta and the uterus. Decomposi- 
tion of the non-adherent portions is produced by the introduc- 
tion of air during the escape of the embryo, or through the 
subsequent passage of the finger into the uterus, or where 
portions of the ovum hang down into the vagina, by ab- 
sorption of septic matter from the vagina upwards into the 
uterus. As a, result of putrid decomposition, the woman is 
exposed to septicaemia, and inflection of thrombi at the placental 
site. Fatal results are, however, rare, as decomposition is usu- 
ally a late occurrence, setting in, as a rule, only after protective 
granulations have formed upon the uterine mucous membrane, 
and after complete closure of the uterine sinuses. Continued 
fever, with intercurrent attacks of hemorrhage, is, however, 
set up, but finally passes away with the gradual discharge 
of the decomposed particles, while the threatening symptoms 
subside. Still, now and then septic processes lead to an un- 
favorable termination. Local perimetritic inflammation is a 
common event. 

4. Where there is a certain degree of relaxation with enlarge- 
ment of the uterine cavity, the fibrin of the extravasated blood 
may become deposited about any uneven surface within the 
uterus, and give rise to a poly shaped body, suggestive in its 
mode of development of the stalactite formations in calcareous 
caverns. These so-called fibrinous polypi generally develop 
around the debris of an abortion, such as retained bits of de- 
cidua, placental remains, and portions of the foetal membranes. 
In some cases, likewise, thrombi projecting from the placental 
site become the base of a loose fibrinous attachment. Placental 
polypi give rise ultimately to bearing down pains, and inter- 
current hemorrhages. They may even decompose, and endanger 
life by septic absorption. 

Expulsion of One Fcetus in Twin Pregnancy.— In twin 
pregnancy one ovum may be blighted and expelled, and the 
other retained till completion of the full term of utero-gesta- 
tion. A most interesting case of this kind was reported by Dr. 
E. Chenery. A woman at the fifth month presented the usual 
symptoms of abortion, and a foetus in its envelopes, together 
about the size of a common open-faced watch, was expelled. 
Upon making a vaginal examination the head of a much larger 
foetus was found protruding through the os uteri. This was 
seized by the fingers for the purpose of extraction, but it escaped 
and returned to the uterine cavity. The physician, supposing 



Premature Expulsion. 169 

that expulsion was then a necessity, gave ergot, but the os con- 
tracted, and the uterus refused to act. When the full term of 
pregnancy was accomplished, expulsion took place in a normal 
manner. 

Another case of similar kind was reported by Dr. Stanley 
P. Warren, of Portland, Maine, in 1887. Other cases are on 
record. In general, however, in multiple pregnancy, the uterus 
is entirely evacuated without a long interval of repose. 

Diagnosis.— Contemplation of the symptoms of abortion 
as related would lead one to suppose that diagnosis of the 
approaching occurrence should not be attended with much 
difficulty. Still, in many cases this is not true. The woman, 
perhaps, has evinced her pregnant state by the usual symp- 
toms, and now hemorrhage and pain indicate its threatened con- 
clusion. The case is clear, and diagnosis unequivocal. But 
we often meet women who are worshiping at the shrine of the 
goddess Isis. So extremely desirous are they to present their 
husbands with heirs, that every possible sign of pregnancy has 
been magnified as a support to fond hopes, and the symptoms 
now presented, though really those of a menstrual return, are 
construed to be signs of abortion. There are women of opposite 
desires and tendencies who will minimize every true symptom, 
and thus mislead themselves, as well as those who are sum- 
moned to their aid. Then there are those unfortunate females, 
many of them girls scarcely out of their teens, who, having 
fallen prey to the wiles of designing men, use every endeavor 
to conceal the evidences of guilt. Among the number are found 
some to whom we would scarcely dare impute wrong-doing, and 
who thereby disarm suspicion. The only safe course for the phy- 
sician to pursue is to insist upon an examination per vaginam 
in all cases where, from the symptoms, there appears to be the 
least possibility of threatened, or partially completed, abortion. 
The diagnosis is based upon the presence of pain, hemorrhage, 
dilatation of the cervix, and descent of the ovum. If the os 
has become patulous, the ovum may be felt, when the demon- 
stration becomes complete. In all cases of pregnancy, the 
occurrence of hemorrhage, even unaccompanied by other 
symptoms, ought to be accepted as a probable evidence of 
threatened abortion, and every precaution accordingly exer- 
cised. 

It is impossible to make out with certainty, from mere sub- 
jective symptoms, the existence of pathological changes in the 



170 Pregnancy. 

ovum and deciduse which prepare the way for abortion. Death 
of the embryo may be inferred from the signs given in another 
chapter; but positive knowledge can be obtained only at a later 
period. 

Whenever the discharged substances have been preserved, 
the physician should carefully examine them with a view to 
discovering every possible trace of the ovum. The clots may 
be broken up in cold water, and solid substances wholly freed 
from extraneous matters. The ovum, when unruptured, is 
generally found surrounded by layers of coagulated blood, and 
may easily be overlooked. If the discharged substances have 
not been preserved, and the os uteri will not admit the point of 
the finger, it may be impossible to determine at once whether 
complete evacuation has been effected or not. Forcible meas- 
ures are not justifiable for mere diagnosis. The occurrence of 
further pain and hemorrhage would constitute strong evidence 
of retention, and dilatation of the osmay be necessary as a pre- 
liminary to extraction of the remaining substances. 

Prognosis. — Of prognosis as regards the foetus, of course 
nothing need be said. The maternal mortality from abortion 
is not great, but the pernicious effects on health are very 
decided. More feebleness and suffering proceed from this source 
than from labor at term. Women frequently urge, as an ob- 
jection to continuing the pregnant state, that their health is so 
feeble as wholly to disqualify them to endure the strain of preg- 
nancy and labor, but assume that interruption of pregnancy 
will protect them from subsequent physical ailments. The 
minds of women ought to be disabused of such erroneous no- 
tions. The hemorrhage which usually accompanies premature 
expulsion of the ovum does not often destroy life, but it so re- 
duces the strength, and hence the powers of resistance, as to 
create inviting subjects for the inroads of disease. 

Criminal abortion is quite another thing, and if we could 
gather reliable statistics concerning the results of it, the mor- 
tality would be shown to be very heavy. The professional 
abortionist frequently makes of himself a professional execu- 
tioner. 

Treatment. — The treatment of abortion is : 1. Preventive ;; 
2. Promotive; and 3. Remedial. 

Preventive Treatment. — This involves (a) general and 
special prophylaxis, and (b) the arrest of threatened abortion. 

The pregnant woman, and especially she who has already 



Premature Expulsion. 171 

suffered one miscarriage or more, should attend most scrupu- 
lously to the observance of general sanitary rules. Over-in- 
dulgence and over-exertion are particularly to be avoided. No 
amount of exercise should be laid out for pregnant women 
indiscriminately, for what may justly be regarded as moderate 
exercise in one case, will far exceed the endurance of another. 

Women who have had repeated abortions, at or near a 
certain period in pregnancy, must be guarded with the greatest 
care. 

It is sometimes advisable to put them in close quarantine, 
and even in bed, for a time, though no threatening symptoms 
have arisen. When the period at which, in individual cases, an 
interruption of pregnancy generally occurs, has been safely 
passed, the woman's restraints may be gradually relaxed, until 
they have been reduced to a minimum. So strong a propensity 
is sometimes generated by recurrent abortions, that the unex- 
pected arrival of a friend, a visit to the table, or even a strong- 
odor, may be sufficient to bring on the accident. 

For these discouraging cases of habitual abortion we would 
especially recommend the following remedies : 

Sulphur for women who are thin and feeble, with dry skin 
and poor complexion. Yery sensitive to vaginal examination. 
Sense of weakness in genitals. They have usually menstruated 
sparingly. 

Arsenicum iod. for scrofulous women, especially those who 
have, or have had, eczema. The skin is easily irritated. 

Calcarea carb. is likewise suited to scrofulous subjects, 
especially those with fair skin, light hair and rotundity of form. 
They give an account of habitually profuse menstruation. 

Caulophyllum when the woman has suffered from myalgia; 
is a poor sleeper; has a history of "female weakness." 

Sepia. — We regard this as one of the best remedies for use in 
• these cases, especially in nervous, sensitive women. Complains 
of much bearing towards genitals ; cannot sleep well. 

Kali iod., mere, iod., nitric acid, and other remedies, may be 
called for when there is a syphilitic taint. 

The treatment of chronic and acute disease in general, of 
which the woman may be the subject, is also included in 
prophylaxis, but methods of treatment and the selection of 
remedies are modified so little by the patient's pregnancy as not 
to demand extended consideration here. The same may be said 
also of accidents, from which pregnant women are not exempt. 



172 Pregnancy. 

Since strong emotions, which in a non-pregnant state could 
do no harm, are capable of producing, during gestation, most 
serious consequences, they ought to receive attention. After 
violent anger, colocynth and chamomilla are of considerable 
service. When anger or vexation is associated with fright, 
aconite may be employed. It is also of service when, after 
fright, a state of apprehension and dread remains. Opium also 
has the reputation of effecting favorable results after fright. 
To avert the evil effects of grief we can probably do no better 
than to administer ignatia or phosphoric acid. 

After a, bruise a few doses of arnica ought not to be omitted. 
A strain generally excites uterine action by rupture, to a certain 
extent, of the utero-placental relations; still, good may occa- 
sionally be done by the timely administration of rhus toxico- 
dendron. 

After marked symptoms of threatened abortion have ap- 
peared, the first point to be settled is, whether the abortion 
ought to be, or can be, prevented. In general, the physician 
should firmly and conscientiously be in no way accessory to 
abortion, and only when he is convinced that the foetus is dead, 
or that discharge is inevitable, should he assume the responsi- 
bility of promoting the act already begun, or passively permit 
the consummation of it. This principle of action, closely fol- 
lowed, gives considerable scope for the employment of prevent- 
ive measures, when once the expulsive forces of tfie uterus have 
been aroused. 

Little time should be lost in getting the woman into a bed, 
w 7 hich has cool, pleasant, and quiet surroundings. Her cloth- 
ing ought to be removed, and loose garments substituted, at 
the earliest practicable moment. If the hemorrhage is profuse, 
the hips may be raised by something laid directly under them, 
or, better still, by setting the foot of the bed upon blocks. In 
a certain percentage of cases, perfect repose of body and mind 
is the only essential, but when painful uterine action has been 
excited, when the hemorrhage is profuse, or when a passive flow 
has existed for some time, further means of prevention will be 
required. The similimum of the case should be sought, and if 
found, it may quiet the pains and arrest the flow in a magical 
way. 

There are a few remedies which we have found of frequent 
service at such a time; but let us not forget that, whenever any 
remedy is called for by clear indications, whether its special 



Premature Expulsion. 173 

sphere of action is the generative, or not, it should be admin- 
istered . 

Sabina is a prominent remedy, especially in threatened 
abortions about the third month of pregnancy. The hemor- 
rhage is rather profuse, of a bright red color, and is accom- 
panied with clots. Its action is more prompt and efficient in 
nervous, hysterical women, but need not be limited to such. In 
the absence of clear indications for some other remedy, we do 
well to employ this. 

Secale cor. is best suited to thin cachectic women, and to 
late abortions. The flow is passive and more like the menstrual 
discharge. The pains are not very vigorous, but rather pro- 
tracted. 

Caulophyllum. — The pains are spasmodic and pressive, but 
the flow not necessarily profuse. The woman is uneasy and 
sensitive. Tremulous weakness. 

Pulsatilla. — Especially for mild, tearful women; but irrita- 
bility of temper is sometimes a good indication. In those 
cases where the sudden spurts of blood are unusually profuse, 
with only a moderate flow in the intervals. 

Viburnum. — It has been highly extolled by some. Our own 
experience with it has been very limited, and we are aware of 
no special indications for its use. 

Ipecac. — When the hemorrhage is profuse, and blood. bright 
red. It is more likely to be efficacious in women with a history 
of profuse menstruation. 

Gratifying results are often obtained from the above rem- 
edies. To them we may add aconite, with its great fear of 
death, and of stir, or bustle; nux moschata, with its hysterical 
symptoms and syncope; belladonna, with its bearing-down 
sensation, and bright red blood, which feels hot to the parts 
over which it flows; apis, with its stinging, tearing, aching 
pain ; and gelsemium, with its pains running up the back. 

In old-school practice, opium constitutes the great reliance 
for the prevention of abortion in these instances where threat- 
ening symptoms have arisen, and there is no sort of doubt 
that it proves efficacious in many cases which Would otherwise 
culminate in expulsion. This fact should not be ignored, and, 
when other remedies do not produce prompt results, we need 
not hesitate to avail ourselves of the benefits derivable from a 
discriminative use of the drug. The most efficacious mode and 
form of administration is the hypodermic injection of morphia. 



174 Pregnancy. 

One-eighth to one-fourth grain will generally be an adequate 
dose. Begin with the minimum quantity, and repeat it if 
necessary. 

In every case of threatened abortion occurring during the 
first three months of pregnancy, a careful examination ought 
to be made to ascertain the situation and position of the 
uterus. In some instances the symptoms depend upon retro- 
flexion and retroversion, and they often quickly disappear 
when, upon placing the woman in the knee-chest position, and 
carefully using the fingers, or the elevator, the organ is re- 
turned to its normal position. 

It is evident that preventive treatment is not suitable to 
all cases. The consummation of the process is sometimes 
clearly inevitable from its very incipiency. For a considerable 
time there may have existed evidence of the subsidence of the 
normal developmental activities, resulting, doubtless, from 
foetal death. The usual symptoms of pregnancy have become 
less pronounced ; there is a sense of weight and bearing in the 
pelvis, associated with a feeling of coldness in the abdomen, 
and sometimes a vitiated vaginal discharge. The woman is ill 
in body, and distressed in mind. In such a case interruption of 
pregnancy should never be prevented. On the contrary, cases 
which at first appear to be preventable, may, by a persistence 
and an aggravation of symptoms, ultimately pass the bounds, 
and become unqualifiedly unavoidable. 

The signs of inevitable abortion are, profuse hemorrhage, 
with regularly recurrent uterine pains, dilatation of the os exter- 
num, descent of the ovum, and rupture of the membranes. 
While we cannot concur in the opinion expressed by some 
authors that rupture of the membranes is not proof positive 
that abortion is inevitable, we would caution against too hasty 
a presumption of its inevitability. Scanzoni has reported a 
remarkable case in which a woman was seized with profuse 
hemorrhage from the uterus in the third month of gestation; 
numerous clots were discharged, and all hopes of preventing 
the threatened occurrence were dissipated ; ergot was given in 
full doses, the Vagina was packed for many hours, and a sound 
was passed into the uterine cavity. After the hemorrhage had 
continued actively and passively for three weeks, a weak solu- 
tion of perchloride of iron was injected ; but, despite all 
interference, the pregnancy continued, and uickening was 
experienced six weeks later. 



Premature Expulsion. 175 

Promotive Treatment. — When the case has advanced be- 
yond the limit where preventive treatment is available, the 
existing conditions do not always favor immediate adoption of 
efforts at uterine evacuation. The os uteri, or, indeed, the 
entire cervical canal, may be so small that it will not admit a 
single finger, while the uterus is pouring out blood in alarming 
quantities. In such an emergency something must be done at 
once to protect the woman from the serious consequences of 
excessive depletion, while the cervix is given additional time for 
expansion. In some cases dilatation may be speedily effected 
with the finger, if the uterus is kept within reach by firm press- 
ure upon its fundus. If the ovum, in early abortion, is found 
intact within the os uteri, no interference whatever should be 
practiced, in the absence of urgent indications, for fear of rup- 
turing it, and thereby complicating the delivery. 

If the uterus cannot be emptied and the hemorrhage con- 
tinue profuse, we may think best to pack the vagina. Still, in 
our own experience we have seen no inexorable demand for the 
tampon, and therefore we never use it. At best it is a danger- 
ous expedient, and, unless we have at hand material for the 
purpose which we know to be strictly aseptic, w T e intend never 
to resort to the operation. The best material for a tampon is 
doubtless iodoform gauze. This should be cut into a long strip 
and gradually crowded into place, the near end being left at the 
vulva, so as to admit of easy removal. 

In the introduction of a tampon much difficulty will be ex- 
perienced, and great suffering inflicted, unless the precaution is 
observed to separate the labia and retract the perineum with 
the fingers of one hand, or by means of a speculum, while the 
article employed is being passed by the other hand. This sub- 
ject is considered at length in another chapter, to which the 
reader is referred. 

Before introducing a tampon, the vagina and vulva should 
be thoroughly washed with a disinfecting solution, and no 
tampon ought to be allowed to remain in situ for more than 
twelve consecutive hours. It can be renewed at the end of that 
time, if necessary, the precaution being taken to cleanse the 
vagina with an antiseptic solution after its removal. The 
ovum often passes into the vagina, when the tampon is taken 
away. If it does not, dilatation may be sufficiently advanced 
to enable the operator easily to remove the fcetus and envelopes 
in an unbroken state. 



176 Pregnancy. 

As soon as dilatation is great enough to admit of interfer- 
ence with a reasonable prospect of immediate success, it should 
be undertaken. In default of this condition, another vaginal 
plug, if required, may be introduced for twelve hours, but the use 
of this expedient for a period much in excess of twenty-four 
hours, is not to be recommended. The vagina becomes irri- 
tated, more or less blood decomposition ensues, and septic 
matters are generated. 

In the practice of many excellent obstetricians the tampon 
is frequently used ; and yet, as before said, we regard it as an 
expedient to be avoided when the indications can be met by 
remedies and other innocuous means. "During the course of 
an average practice of over a quarter of a century," says my 
esteemed friend, Dr. Henry A. Minton, of Brooklyn, "I have 
never resorted to the tampon ; I have never had occasion to, 
the carefully selected remedy has always given such prompt and 
satisfactory results that nothing more was called for." 

Emptying the Uterus. — The secundines, as w r ell as the ovum, 
require removal, and this is not always accomplished with the 
utmost facility. The ovum or placenta forceps have been 
recommended, and can sometimes be successfully used, but 
cannot be regarded as safe except in those cases where the part 
retained protrudes from the os uteri. As will be seen in a suc- 
ceeding paragraph, the fingers afford the safest and best means 
of extraction. 

In miscarriage the foetus is extremely apt to present by the 
feet, and the utmost care and discretion must be exercised to 
avoid parting head and trunk. This is not an uncommon acci- 
dent, though by no means an insignificant one, as a retained 
head is not always easily extracted. In removing the foetus, as 
likewise in getting away the placenta, the operator ought to 
work about the mass, loosening first one side and then the 
other, so that it may not be torn. 

In these rare cases wherein the membranes are expelled and 
the foetus retained, the latter should be extracted without un- 
necessary delay. A foetus left behind would give rise to the same 
dangers as a retained placenta, namely, hemorrhage, and 
septic poisoning, and the rules of practice regarding unexpelled 
secundines would apply with equal force to an unexpelled 
foetus. In the latter case the operation is attended with fewer 
difficulties than in the former. 

It may occasionally happen that the symptoms of abortion 



Premature Expulsion. 177 

culminate in the expulsion of one foetus and its membranes, 
while yet another child, with intact membranes, remains in 
utero. In such cases the physician should assume the expectant 
attitude, and patiently await developments. If there are no 
discernible signs of foetal death, and no further abortive efforts, 
there surely is no excuse for interference. But should symptoms 
of miscarriage continue, or again become manifest, or should 
foetal death or disruption of the membranes be discovered, 
delay ought to be brief, for the woman's interests are best 
subserved by speedy delivery. 

In twin pregnancy, the membranes of the first child may be 
broken before foetal expulsion, and remain behind. In such a 
case we should discreetly await the natural efforts, indulging a 
hope that the placenta will be extruded without serious dis- 
turbance of the uterine relations of the second child. Nature 
failing to accomplish this, and no untoward symptoms arising, 
the case, kept under strict surveillance, may be permitted to go 
undisturbed. It is evident that the existence of twin pregnancy 
is rarely recognized until interference has gone so far as to in- 
sure complete evacuation of the uterus. 

When once the embryo or foetus is expelled, the case has not 
always reached its climax of difficulty and danger. Indeed, in 
many instances serious difficulty is now first met. Expulsion 
of the ovum entire is not an infrequent occurrence in early 
abortion ; but in other cases the embryo is first extruded, to be 
followed without much delay by the secundines. In later preg- 
nancy this sometimes occurs, but in the main, the phenomena 
differ in some important respects. The abortive process goes 
on in a regular way until foetal expulsion has been accom- 
plished, when uterine efforts cease, and the placenta is retained 
for an indefinite period. Nor is such retention generally for a 
few moments only, as in labor at full term, but it is prolonged 
and persistent. 

What gives to such a condition a serious aspect is, that 
there grow out of it certain dangers, namely, hemorrhage and 
septicaemia. After labor at full term, the placenta, on account 
of certain degenerative changes, is more easily separable, and 
may be either expressed or extracted. When retained after 
abortion, the uterus is too small to admit of successful expul- 
sion of the placenta by abdominal pressure, the umbilical cord 
is too frail to bear traction, and the vulva, cervix, and uterine 
cavity, are not sufficiently expanded to admit the hand. These 

(12) 



178 Pregnancy. 

are the conditions which render retention of the placenta after 
abortion a matter of so great moment to both physician and 
patient. 

When and How to Remove the Secundines.— When the 
placenta is retained it sometimes becomes a point of great 
nicety to decide when to operate for its removal, and unless 
one has settled rules of practice for his guidance he will be likely 
to stumble and vacillate in a very embarrassing way. Physi- 
cians are not in perfect accord with regard to the treatment 
of these cases, and the consensus of opinion is not easily 
gathered. Many advise against early interference, preferring 
to wait hours, or even days, for natural expulsion. Others 
insist upon the advisability of immediate attempts to remove 
the retained secundines, even though the operation prove to be 
difficult. 

The placenta proper is not formed until the third month of 
pregnancy, but the proper embryonic envelopes of an earlier 




Fig. 106. — The ovum Forceps. 

date constitute a mass several times larger than the embryo 
itself, and require treatment varying but little from that given 
the placenta. We find, however, that the uterine cavity and 
cervical canal are so small at an early period in pregnancy, 
that the finger is not always available, in which case interfer- 
ence should not be pushed to extremes, unless hemorrhage 
becomes troublesome, or there is intimation of septic in- 
fluences ; and then, the finger failing, the curette should be care- 
fully employed. Such masses left in utero, being small, do not 
often create serious disturbance ; but they ought not to be left 
for an indefinite period, A safe rule of practice is to resort to 
the curette without much delay when there are persistent indi- 
cations of incomplete abortion. 

In abortions of the third and fourth months, the treatment 
should differ from this in some important respects. The 
placenta is now formed, and must be removed; but when? 
.and how? 

The question " when" is one which merits more than a brief 



Premature Expulsion. 179 

answer. It has engaged the attention of obstetricians for 
many years, and has been discussed with much fervor. For- 
merly the practice was to follow the expectant mode of treat- 
ment, keeping careful surveillance of the patient, and interfering 
only w T hen serious symptoms began to manifest themselves In 
1883 Dr. T. Johnson Alloway, of Edinburgh, in a communica- 
tion to the American Journal of Obstetrics, took strong 
grounds in favor of immediate removal, in such cases, of the 
retained secundines. In the same number Dr. Paul F. Munde, 
being incited thereto by Dr. Alloway's communication, went 
over the subject in a thorough manner, and unhesitatingly 
advocated a similar treatment. The following excerpt is from 
that article, the italics being ours : 

" The future safety of the patient demands that the secun- 
dines should be at once removed after expulsion of the foetus, 
in every case of abortion in which such removal can be accom- 
plished without force sufficient to injure the woman." In the same 
journal, during the succeeding year, two other articles appeared 



Fig. 107. — Leavitt's uterine Curette. 

favoring the same treatment, one by Dr. S. Henningway and 
the other by Dr. G. N. Acker. We also observe that Dr. Egbert 
H. Grandin, in his translation of Charpentier's excellent treatise, 
advocates the same treatment. 

This has been our own method of management for some 
seven or eight years, and we have had no reason to regret its 
adoption. 

On the other hand, a large number of excellent obstetricians 
still favor the expectant plan, and in pursuing it, allow the 
placenta in some cases to remain for two or three days. 

Immediately after expulsion, or extraction of the foetus, the 
cervical canal ought to be examined, and if expansion be great 
enough to admit the finger, the placenta should at once be re- 
moved. With one hand on the hypogastrium the uterus can be 
pushed down into the pelvic cavity, and its contents thus 
brought within reach, when by gentle manipulation the entire 
mass may be removed. If the cervical canal will at first admit 
the finger nearly or quite to the internal os, gentle endeavor 



180 Pregnancy. 

will soon overcome resistance. We have often oeen surprised 
to find the finger easily penetrating the cervical canal, when, to 
a superficial examination, the os seems quite too small 
to receive it. If neither dilatation nor moderate dilatability 
exist, the operation should be delayed for a time, though the 
placenta ought not to be permitted to remain longer than 
twenty-four hours, unless violence in its removal would be 
unavoidable. 

The chief exceptions to the foregoing rules arise in connection 
with those cases wherein the woman has either been greatly 
reduced by hemorrhage, which has temporarily ceased, or is in 
a state of extreme nervous erethism. Either of these conditions 
would contra-indicate interference. In the former case the 
patient must be kept under strict observation, while time is 
given the natural energies to recuperate. China, or some better 
indicated remedy, should meanwhile be administered. In event 
of recurrence of the hemorrhage the placenta should at once be 
removed. For the nervous irritability which may stand in the 
way of immediate interference, the most effective remedies are 
act sea racemosa, caulophyllum, ignatia, hyoscyamus, asarum, 
camphor (2 X ), coffea, stramonium, kali brom., or even chloral 
hydrate. 

Delay in excess of twenty-four hours ought not, as a rule, to 
be permitted. Bring the patient carefully under the influence 
of an anaesthetic, and proceed with the necessary operative 
measures. In truth, it often happens that when the placenta is 
is retained, the woman, especially if of a nervous organ- 
ization, is thrown into a condition of extreme nervous 
excitability, which cannot be wholly relieved while the placenta 
remains. 

In abortions at the fifth month, operative procedures should 
not be delayed longer than ten or twelve hours. In abortions 
at the sixth month, we should not wait longer than two or 
three hours. 

There are remedies which contribute a certain amount of 
aid towards expulsion of the uterine contents in these cases of 
incomplete abortion, and among them stands pre-eminently 
Sabina. China has been spoken of in high terms by some. If 
enough blood has been lost to produce an effect on the pulse or 
sensorium, this remedy will be peculiarly suitable. Pulsatilla 
has rendered good service in many cases. These remedies may 



Premature Expulsion. 181 

fail to expel the placenta, and yet, by encouraging uterine 
action and consequent dilatation of the cervical canal, render 
efficient aid to extractive measures. 

In a moderate percentage of cases we succeed with digital, 
or even instrumental, efforts at removal, without an anaes- 
thetic; but, in most instances, it is either advisable or neces- 
sary to resort to it. 

Abortions at the fifth and sixth months can usually be 
terminated by delivery of the placenta as in labor at full term. 
It may be necessary to introduce the half-hand ; but our experi- 
ence has not led us to think so. 

When the placenta has been removed in fragments, or when, 
in the absence of positive knowledge of what has been extruded, 
the finger is introduced for exploratory purposes, the rough- 
ened endometrium may lead one to suppose that something 
still remains. It is only by most painstaking examination 
that the truth can be elicited. 

The placenta is sometimes so closely adherent to the uterus 
that removal of the entire mass, even in fragments, is impossi- 
ble, and there remains the danger of hemorrhage and septi- 
caemia. If profuse hemorrhage should at any time occur, water 
at a temperature of say 118° to 122° Fahrenheit, injected di- 
rectly into the uterine cavity by means of a syringe throwing a 
gentle stream, free from air, is a most excellent means of over- 
coming it. There is little or no danger connected with this use 
of hot water, provided the os be large enough to permit free 
escape of the fluid injected. Such an injection ought never to 
be made by other than the medical attendant or a % skillful 
nurse. A hot vaginal douche often answers well to keep the 
flow within bounds, and it may be resorted to before using the 
intra-uterine douche. 

Similar injections have been given with excellent results for 
hemorrhage consequent on total retention of the secundines, 
substituting the tedious and painful use of the finger, or instru- 
ments. In most cases the uterus is stimulated to immediate 
contraction, and, when the cervical canal is sufficiently ex- 
panded, the result is usually placental expulsion and arrest of 
hemorrhage. 

When by the means described we are unable to depress the 
uterus far enough to admit of digital or instrumental extrac- 
tion of the placenta, we may cause the organ to descend by 
means of the volsella. Abortions are much more frequent in 



182 Pregnancy. 

multigravidse than in primigravida?, and it is chiefly in the 
latter, and in thofce whose abdominal walls present an un- 
usual thickness of adipose tissue, that the fingers, aided by 
abdominal pressure alone, will fail. In these exceptional cases 
we may seize the cervix with the volsella, one with a slight curve 
being preferred, passing one blade within the os for about half 
an inch, and placing the other upon the outer aspect of the 
cervix at a corresponding level. With a hold thus obtained, 
the uterus may be drawn down without injury either to it or 
its ligaments, and held by one hand, while we operate with the 
other. If other instruments are used, care of the volsella must 
be given to an assistant. 

Precedence and preference are by some given the placenta 
forceps and the small blunt hook as a means of extracting the 
placenta; but most operators prefer the fingers. StiH there 
are cases in which, from our inability to bring the uterine cavity 
within reach, or from the shortness of the fingers, the instru- 




Fig. 108. — Leavitt's placenta Hook. 




ments mentioned are capable of rendering efficient aid. Sep- 
aration of adherent portions of the placenta should never be 
entrusted to instrumental means, unless the sense-guided 
fingers utterly fail. The placenta forceps are constructed with 
slim shanks, and sometimes spoon-like blades, the inner surface 
of the latter being roughened, so as to afford a firm hold. In 
order to pass the instrument, the fingers of one hand should be 
laid in the vagina, with their points at the os uteri, and along 
their palmar surface the instrument can be directed into the 
uterus. With the handles well back against the perineum, the 
blades are separated and an effort made to inclose the placenta. 
This is an operation which requires some skill, and, like many 
other obstetric procedures, is more easily described than suc- 
cessfully performed. Extreme care should be exercised to avoid 
traumatism. When the placenta is taken hold of, forcible 
traction ought not to be made, as its fragile structures are 
easily broken. By gentle rotation of the instrument, first one 
way and then the other, associated with moderate traction, the 
retained part can sometimes be delivered in one mass. 



Premature Expulsion. 183 

Small hooks have been provided with which to remove the 
placenta. We present a cut of an instrument of this kind 
Avhich we have found most effective. The stern has a sigmoid 
flexure, which favors easy introduction of either end, and the 
fenestrated hooks are intended for use, one on the anterior, 
and the other on the posterior, wall of the uterus. By gentle 
manipulation and deft search of the uterine cavity, the retained 
secundines can be secured and slowly drawn away. 

In nearly all instances bleeding ceases as soon as the uterus 
is fully evacuated ; and when it persists, especially if it comes 
in little gushes, at intervals, we may be quite sure that a 
fragment of the ovum, or a hard coagulum, remains behind. 
The finger should be again passed, if the cervix will admit it, 
and every part of the uterine wall examined. If anything is 
found it must be removed. If bleeding si ill continue, as it will 
rarely do, the cavity should be scraped with the curette. 

Neglected Cases. — The most threatening emergencies which 
the physician is called to meet, sometimes grow out of the neg- 
lect of women to avail themselves, in season, of professional 
care. It is assumed that the abortive act has been consum- 
mated, until, after the lapse of days or weeks, serious symptoms 
are manifested. A passive flow has existed for some time, 
when suddenly the blood gushes forth so profusely that the 
woman's life-forces are speedily brought low. A physician is 
hastily called, and he finds his patient exsanguine and synco- 
pal. The flow has temporarily ceased. Keflecting upon her low 
state, and realizing that the last few drops are those which kill, 
his good sense tells him that the present is no time for interfer- 
ence. The voice of a wise monitor whispers: "To disturb 
those clots may be to kill," and he wisely heeds it. He revives 
his patient by judicious stimulation, and the administration of 
china, while a constant watch is kept to prevent an unobserved 
renewal of the flow. Should it occur, he will remove the secun- 
dines with out delay ; but in its absence, time for recuperation 
of the vital forces is given, and then the case is terminated 
without danger. 

In another instance the placenta, through neglect, is suffered 
to remain in utero. After a time certain ill-feelings are experi- 
enced : there is a chill, the pulse is accelerated, the temperature 
rises; then follow headache, backache, fetid discharges, pros- 
tration, and all the signs of what has been called irritative fever. 
A physician is called in to explain the slow "getting up, 5; and 



184 Pregnancy. 

recognizes the alarming condition of his patient. He does not 
hesitate nor delay :— the uterus is at once emptied and washed 
out with a disinfecting solution. This treatment is generally 
followed by marked and immediate improvement; but some- 
times the poisonous matters have been absorbed in so great 
quantities, and suitable treatment has been so long delayed, 
that the patient cannot be rallied. 



Pathology of the Uterine Mucosa. 185 



CHAPTEK IX. 

PATHOLOGY OF THE OVUM AND DECIDUJE. 

The physiological changes which take place in the uterine 
mucous membrane as the result of impregnation, sometimes 
pass the usual bounds and become pathological. It appears 
probable that abortion not infrequently owes its origin to such 
a cause. 

Endometritis.— This may be either acute or chronic. The 
latter variety of the affection is divided into three distinct 
forms, namely, 1. Endometritis decidua chronica diffusa; 2. 
Endometritis decidua tuberosa et polyposa, and 3. Endome- 
tritis decidua catarrhalis. 

The causes of the first form probably depend, in a great 
measure, on endometritis which antedates conception. Syphi- 
litic infection, excessive physical exertion, and foetal death, 
with retention, are also set down as etiological factors. The 
anatomical changes which take place consist in thickening and 
hardening of the decidua, resulting from diffuse development of 
new connective tissue, and proliferation of decidual cells. The 
decidua vera and decidua reflexa may be separately or jointly 
involved in the processes, and changed in whole or in part. 
According to Duncan, the hypertrophied decidua always pre- 
sents evidence of fatty degeneration, unequally advanced in 
different parts. When the changes are wrought in the latter 
part of pregnancy, they pursue a notably chronic course, are 
limited in extent, do not involve the placental decidua, and 
pregnancy does not invariably suffer interruption. Premature 
expulsion is caused in these cases by death of the ovum from 
imperfect nutrition, or by the exciting of reflex uterine action. 
The ovum, after death, generally retains its connection with 
the decidua for a time, and finally the diseased decidua 
and attached ovum are expelled. The decidua is a thick 
triangular fleshy mass, and has attached to some part of its 
inner surface, the blighted ovum. Expulsion is apt to be a 
slow process, owing to the adhesions which have formed be- 
tween the decidua and the deeper uterine tissues. If these 
include the placental decidua, much difficulty will be experienced 
in natural separation, and the case is liable to be complicated 
by profuse hemorrhage. 



186 



Pregnancy. 



The causes of the second variety of chronic endometritis are 
obscure. Virchow regarded syphilis as one of them. Gusserow 
says that when conception closely succeeds delivery, the re- 
cently formed vascular uterine mucous membrane may take on 
abnormal proliferative processes. This variety of endometri- 
tis and the succeeding- pathological changes are limited, with 
rare exceptions, to the decidua vera, and prefer for their loca- 
tion the anterior and posterior walls of the cavity. "The 




Fig. 109. — Hypertrophied Decidua laid open : Ovum at the fundus. 



uterine surface of the decidua is rough, and covered with 
coagulated blood, while the entire mucous membrane is ex- 
ceedingly vascular. Upon that surface of the decidua which is 
directed towards the ovum, are situated large excrescences or 
elevations, the prevailing shape of which is polypoid. They 
may, however, appear in the form of nodules, of cones, or boss- 
like projections, provided with a broad, non-pedunculated base. 
Their height is from one-quarter to one-half inch, and their sur- 
face is smooth, very vascular, and devoid of uterine follicles. 



Pathology of the Uterine Mucosa. 187 

The latter, however, are plainly visible on the mucous mem- 
brane intervening between the polypoid outgrowths, but they 
are compressed, and their orifices constricted or obliterated by 
the pressure of whitish, contracting bands of newly developed 
connective tissue. Similar fibrous bands surround the 
blood-vessels. On section, the larger prominences sometimes 
appear permeated with coagulated blood, and narrow, cord- 
like bands of hypertrophied decidual tissue occasionally form 
bridge-like connections between neighboring polypi. The uterine 
follicles are, in some cases, filled with blood-clots. The epithe- 
lium is often absent from the uterine surface of the decidua, 
except around the orifices of the follicular glands, and the 
deeper decidual tissues contain large numbers of lymphoid 
cells. The cells of the decidua reflexa frequently undergo fatty 
degeneration. The placental villi may show hypertrophy of 
their club-shaped ends, or be the seat of myxomatous growths, 
in which case their cells are granular and cloudy. The fuetus is 
generally dead and partially disintegrated. This form of 
endometritis decidua is, consequently, usually accompanied by 
abortion, which occurs predominantly at an early stage of 
pregnancy."— Lusk. 

The third form of chronic endometritis attacks multigravidae 
oftener than priniigravidae, and runs a comparatively mild 
course. It has been termed hydrorrhea gravidarum, by 
which is meant a collection of yellowish watery albuminous, and 
sometimes bloody, fluid between the decidua reflexa and vera, 
which is discharged at intervals during pregnane}'. Many theo- 
ries have been formed regarding its etiology. Some have re- 
garded the discharge as due to rupture of a cyst between the 
ovum and uterine walls. Baudelocque thought it proceeded 
from transudation of the liquor amnii through the membranes, 
while Burgess and Dubois believed it depends on rupture of the 
membranes at a point distant from the os uteri. Mattei has 
referred it to the existence of a sac between the chorion and 
amnion. A single discharge doubtless occasionally proceeds 
from the two last-mentioned causes, but repeated loss must be 
referred to other sources. Hegar's theory, that it is the result 
of abundant secretion from the glands of the uterine mucous 
membrane, which accumulates between the decidua and chorion, 
and escapes through the os uteri, is probably nearer the truth. 
The real pathological changes which take place are vascularity, 
hyperemia, and hypertrophy of the interstitial connective 



188 Pregnancy. 

tissue, and of the glandular elements of the decidua. The in- 
flammation involves the decidua vera by preference, but may 
simultaneously affect the decidua reflexa. The fluid which re- 
sults is thin, watery, muco-purulent, or sero-sanguinolent, re- 
sembling the liquor amnii both in color and odor. When no 
obstacle to its free escape is interposed, its discharge is contin- 
uous, but when it is confined, a considerable quantity may col- 
lect, until finally the resistance is overcome, and there is a 
sudden and copious discharge. It is often expelled at night 
while the patient is sleeping, very likely by reason of uterine 
contraction. In some cases even a pound, or more, of the 
fluid is thus lost. Hydrorrhcea gravidarum is observed at 
all periods of pregnancy, but most frequently in the latter 
months. It often occurs as early as the third month. 

Diagnosis involves differentiation between it and rupture of 
the membranes, escape of fluid sometimes confined between the 
amnion and chorion, and escape of fluid emanating from the 
hypertrophied decidual glands. The chief point of differentia- 
tion between hydrorrhea and escape of fluid from the space be- 
tween the amnion and chorion, is that in the latter case there 
is but a single discharge, while in the former there is either con- 
tinual draining or repeated gushes. It is not always easy to 
distinguish between hydrorrhcea and escape of the liquor amnii. 
In the former we And that pains are absent, the os uteri un- 
opened, and ballottement can be made out. If the membranes 
are ruptured, labor is quite certain to ensue, though cases of 
long retention after rupture have been recorded. A repetition 
of the discharge, and continuance of pregnancy, will materially 
aid in clearing up the diagnosis. Hydrorrhcea, though apt to 
cause alarm, rarely presents serious phases, though Veit says 
that the uncontrollable vomiting of pregnancy is sometimes 
attributable to it. The pregnancy is rarely interrupted, and the 
woman feels rather relieved by the discharge. During the exist- 
ence of this form of endometritis the general health of the 
woman should be as well maintained as possible, by strict 
observance of hygienic principles. Sexual intercourse, vaginal 
douches, and all possible sources of local irritation, should be 
avoided. The remedies, among which we shall be most likely to 
find the similimum, are arsenicum album, lachesis, natrum mu- 
riaticum, mercurius, calcarea carb. and sulphur. If uterine con- 
tractions supervene, the utmost quiet must be insisted upon, 
and caulophyllum, Pulsatilla, or viburnum administered. 



Pathology of the Ovum. 



189 



Pathology of the Chorion.— The only affection of the 
chorion that has yet been described is that form of degenera- 
tive change which results in the development of what is known 
as vesicular or hydatidiform mole (cystic disease of the chorion, 
hydatidiform degeneration of the chorion). It is of rare occur- 
rence. Madame Boivin saw but one case in 20,375 delivered. 
Before the time of Cruvelhier, the vesicles which characterize 
this morbid product were, from their close resemblance, sup- 
posed to be real hydatids. 




Fig. 110.— Hydatidiform Mole. 




Fig. 111. — Hydatidiform Mole. 
(Placental origin.) 



There is a little disagreement concerning the structures 
involved in the myxomatous degeneration here considered, 
careful dissection disclosing the villi of the chorion in various 
stages of change; but still there is not perfect accord concern- 
ing the histological elements affected. Heinrich Miiller locates 
the affection in the external membrane covering the villi. 
Mettenheimer maintains that a cystic transformation of the 
cells of the interior of the villi is the essential pathology. His 
views are also shared by Pajot. Virchow locates the morbid 
change in the villi and holds that what fluid there is, is simply 
the intercellular tissue fluid. His views have been most com- 
monly accepted. The resulting vesicles vary in size from that 



190 Pregnancy. 

of a millet seed to that of a walnut. The vesicular fluid con- 
tains musin, but the large cysts a less quantity than the 
smaller. All the villi are not involved in the morbid process. 
Development is by gemmation or budding, not from single 
stems, but mainly from vesicles already formed. They frequent- 
ly aggregate a considerable mass and present the general 
appearance represented in figures 110 and 111. 

When degenerative development begins in the first month of 
pregnancy, as indeed it usually does, the degeneration involves 
the whole chorionic surface. Death and absorption of the 
embryo may ensue, leaving the amniotic cavity entirely free 
from solid matters. If the placenta has already been formed, 
degenerative changes do not go beyond this structure, and if 
sufficiently extensive to destroy the foetus, the remains of the 
latter are found in the amniotic cavity, which sometimes 
contains an excess of fluid. If only a few of the placental 
cotyledons are implicated, the foetus may continue its func- 
tional activity for a time, and even reach perfection. The 
morbid changes generally take place within the decidua sero- 
tina, bat that boundary is sometimes exceeded. Volkmann 
reports a case in which the degenerative process invaded the 
uterine blood sinuses, and, by pressure, led to so extensive an 
atrophy and absorption of the uterine walls, as to leave only a 
thin septum between the mole and the peritoneal covering of 
the organ. "The cavity formed by this process of erosion in 
the uterine parenchyma was larger than the uterine cavity 
proper, and presented intersecting trabecular resembling the 
columnar carnear of the cardiac ventricles." Such results, how- 
ever, probably depend on a morbid condition of the uterine 
walls, proceeding from malnutrition. Similar cases, with fatal 
results, are reported by Schroeder. 

Sometimes the adhesion of the mass to the uterine walls is 
very firm, and may interfere with its expulsion. Nutrition 
of the altered chorion is carried on through its connection with 
the decidua, which also is often diseased and hypertrophied. 

Causes of Hydatidiform Degeneration. — The etiology of this 
disease has evoked considerable discussion. Ruysch, Scanzoni, 
Hewitt and others maintain that the changes in the chorionic villi 
which characterize it are always preceded by embryonic death. 
In support of this view allusion has been made to the fact that, 
in nearly all cases, the embryo has been entirely absorbed, and 
also to the occasional occurrence of hydatidiform degeneration 



Pathology of the Ovum. 191 

of the chorion of a dead foetus in twin pregnancy, while that of 
the living one remains healthy. That the exciting cause of the 
degenerative changes is often, if not usually, a morbid ma- 
ternal condition, seems likely from its repetition in the same 
woman, by its co-existence with endometritis, or with extensive 
uterine fibromata, and by the existence in most cases, according 
to Underhill, of a cancerous or syphilitic dyscrasia in the 
mother. But still better evidence is found in the clinical obser- 
vation that myxomatous changes have been observed involv- 
ing a, part of the placenta with a living child. In Germany the 
opinion prevails that the cause of these degenerative changes is 
found in endometritis. If this be accepted, we must conclude 
that the degenerative changes generally precede and produce 
foetal death. The disclosure of the true pathology of hyda- 
tidiform degeneration has disposed of the question, formerly 
mooted, of its occurrence independently of impregnation. 

Symptoms and Course.— Cystic disease of the ovum may 
exist for a time without developing any symptoms of sufficient 
prominence to draw attention. Later it is observed that the 
ordinary course of pregnancy has been changed in some impor- 
tant regards. Some of its most common symptoms may disap- 
pear, but such changes are by no means constant. The most 
prominent sign of the existence of perverted development 
consists in a failure of correspondence between the uterine en- 
largement and the computed period of utero-gestation. Thus, 
at the third month, the uterus may be found as high as the 
umbilicus, or higher. On the other hand, if the cystic develop- 
ment began early, the organ may be decidedly smaller than at 
a corresponding period in normal gestation. There is more 
general disturbance of the health than there ought to be, nausea 
and vomiting being apt to become excessive. Lumbar and 
sacral pains are prominent and distressing in proportion to 
the rapidity of the abnormal growth. About the third month, 
sometimes earlier, there begins a more or less profuse watery 
and sanguineous discharge, generally at intervals, which re- 
sembles currant juice. These losses doubtless depend on break- 
ing of one or more of the cysts, and escape of the contents, 
brought about by painless uterine contractions. Though not 
usually excessive in quantity, they are sometimes so profuse 
and frequent as to reduce the woman's vital forces to a low, and 
even dangerous, condition. In the discharge are also found 
portions of cysts, and sometimes masses of considerable size. 



192 Pregnancy. 

Expulsion of the degenerate mass usually takes place before 
the sixth month, but it maybe delayed beyond the usual period 
of mature utero-gestation. As in the case of ordinary abor- 
tion, the hemorrhage ceases after the uterus has been com- 
pletely evacuated, but retained portions of the tumor may give 
rise to protracted and profuse bleeding. The entire mass is 
sometimes expelled enclosed in an unbroken decidua. 

Diagnosis.— This will rest in part on subjective symptoms, 
such as the sensations accompanying foetal death ; but mainly 
on objective symptoms. 

The uterus as felt through the abdominal walls sometimes 
presents irregularities, but such as do not closely resemble 
foetal outlines, and the organ imparts to the examining hand a 
peculiar boggy, or doughy feel, with sometimes distinct fluctu- 
ation. On examination per vaginam, the lower uterine seg- 
ment is found to present similar characters. Ballottement 
yields negative results, and foetal movements are not felt, 
though they may be simulated by uterine contractions. The 
sounds of the foetal heart are diminished in intensity in the 
early stage of degenerative change, and subsequently quite lost. 

In these cases where the cystic degeneration implicates but a 
part of the ovum, diagnosis cannot always be made with any 
certainty, unless we observe that duet of characteristic signs, 
rapid increase of uterine development and the peculiar dis- 
charge in which whole vesicles are at times found. Absence of 
the more important signs of normal pregnancy should be given 
due weight. 

Prognosis. — The character of the prognosis in cases of hyda- 
tidiform mole is governed largely by the frequency and violence 
of the accompanying hemorrhages. It is reassuring in the 
majority of cases, as far as it regards the mother; but the life 
of the foetus is, of course, almost invariably sacrificed. 

Treatment. — The treatment differs but little from that pre- 
scribed for ordinary abortion, and consists, in the main, of 
measures calculated to control the hemorrhage, and promote 
expulsion of the degenerate product of conception. Manual 
and instrumental non-interference is generally advised until 
uterine action is excited, unless threatening symptoms are 
meanwhile developed. When contractions begin, the tampon 
should be used, if called for by profuse hemorrhage with inability 
to deliver, and uterine action sustained by appropriate rem- 
edies. 



Pathology of the Ovum. 193 

Under the expectant plan of treatment there is considerable 
danger to be apprehended from sudden and violent hem- 
orrhage ; therefore, unless arrangements of the best sort can be 
made for prompt professional attention, the question of im- 
mediate interference merits thoughtful consideration. Dilata- 
tion may be begun with tents, and afterwards continued with 
the finger, or with the dilators of Molesworth, Barnes or Allen. 
The remaining steps of the operation will be easy. With the 
fingers the mass is removed either whole, or in fragments, and 
the main difficulties of the case are soon overcome. Since there 
is sometimes firm adhesion of the cystic mass to the uterus, 
very energetic attempts at complete separation should be 
avoided. 

The Placenta.— The usually round or oval shape is not 
always preserved, but it maybecrescentic, or horse-shoe shaped, 
or have an irregular form, and be spread over a considerable 
surface, in consequence of an unusual number of the chorionic 
villi being concerned in its formation. That anomaly of form 
which deserves special mention, is the one in which a supple- 
mentary placenta exists. This is known as placenta succen- 
turia, the accessory developments being due to the persistence 
of isolated villous groups, which form vascular connections 
with the decidua vera. They are of consequence, inasmuch as 
they are liable to be left in utero, and give rise to hemorrhage. 
Hohl says they always form at exactly the junction of the 
anterior and posterior uterine walls, and the portions of 
placenta on each side of the line become nearly separated. 

Size.— Placenta? vary also in size, the dimensions of the 
organ bearing a pretty constant relation to that of the child. 
Hypertrophied placentae occur chiefly in connection with hy- 
dramnios, and consist of a genuine parenchymatous hyper- 
plasia, the foetus being dead and shriveled. In some cases the 
organ is remarkably small, which condition is referable to 
defective development, to premature involution, or to hyper- 
plasia of the connective tissue, with subsequent contraction. 
It should be borne in mind, however, that the dimensions of 
the placenta are modified by the state of the placental vessels. 
When the latter are empty, the organ is small, and when 
filled, it is greatly increased in size. 

When true atrophy of the placenta exists, the vitality of the 
foetus is sure to be more or less impaired. Whitaker believes 
that atrophy of the organ depends either on a diseased state 
(13) 



194 



Pregnancy. 



of the chorionic villi, or of the decidua in which they are im- 
planted. The latter is supposed to be the more common cause, 
and it consists in hyperplasia of the connective tissue of the 
decidua, which presses on the villi and vessels, and results 
in atrophy. Placentae have been found in a state of 
atrophy though the tissue of the organ itself showed nothing 
peculiar. 

Situation. — The most frequent situation of the placenta is 
at or near the fundus uteri, close to the orifice of the Fallopian 




Fig. 112. — Fatty Degeneration of the Placenta. 

tube, on one side of the uterus or the other, but it is occasion- 
ally implanted elsewhere, as, for example, over the internal os, 
as in placenta prsevia, and at various points in the abdominal 
cavity in connection with extra-uterine pregnancy. 

Degenerations and New Formations. — The most common 
form of degeneration is the fatty, which may be circumscribed, 
or diffused. It is normally present in a mature placenta, and 
is probably a change which facilitates the final separation of 
the organ. When it occurs early in pregnancy it is often 
responsible for premature completion of the occurrence which 
normally takes place at a later period. Its cause is doubt- 



Pathology of the Ovum. 195 

less referable to tissue changes which interfere with proper 
nutrition, proceeding, perhaps, in the first instance, from the 
woman's state of health. Syphilis, doubtless, in some cases, 
has an influence in its production. The placental tissues often 
present yellowish masses of different sizes, which consist largely 
of molecular fat, penetrated by a fine network of fibrous tissue; 
but true fatty degeneration has a predilection for the chorionic 
villi. The latter, on careful examination, are found to be 
altered in their contour, and loaded with fine granular fat- 
globules. 

Other morbid states of the placenta are: 1. Amorphous 
calcareous deposits, which are found on the uterine surface of 
the placenta, in the decidua serotina. Sometimes these are 
isolated grains or needles, sometimes calcareous masses. They 
are composed of amorphous carbonates and phosphates of 
lime and magnesia. The process sometimes extends to the 
foetal portion of the placenta. When the change begins in the 
latter part, it is generally limited to it, and affects the small 
blood-vessels of the villi, attacking first their terminal ramifi- 
cations, and gradually implicating the trunks. 2. Deposits of 
pigment, usually attributable to alterations in the haemo- 
globin of extravasations, found within the blood sinuses or 
villi of normal placenta?, are sometimes excessive. 3. (Edem- 
atous infiltration of the placental tissue is sometimes observed. 
According to Lange, it occurs only in connection with hydram- 
nios. j 4. Cysts are frequently found near the center of its con- 
cave surface, and vary from a few lines to several inches in 
diameter. Cysts of considerable size have been found also on 
the foetal side of the placenta, but below the amnion and 
chorion. Their contents are solid and liquid. The amnion, 
covered with pavement epithelium, forms the cyst wall. A 
reddish, cloudy, thin fluid, makes up the contents. Ahlfeld re- 
gards the cysts as liquefied myxomatous formations. They 
may also develop from apoplectic foci. 5. Circumscribed 
tumors are occasionally found on the foetal side of the placenta, 
beneath the amnion. Spiegelberg tells us that these are fibrom- 
atous or sarcomatous in character. They sometimes attain 
considerable size. Myxoma of the placenta, consisting in 
h}^perplasia of the villi, and myxoma fibrosum placentae, char- 
acterized by the fibroid degeneration of the basement mem- 
brane in isolated villi, are the chief remaining varieties of 
placental neoplasms. 



i 



196 Pregnancy. 

Syphilis of the Placenta.— According to Charpentier, 
Frankel, in concert with Waldeyer and Kolaezek, was the first 
to give serious attention to the subject. He collected fifteen 
cases of syphilis transmitted from the father, wherein nothing 
more than hypertrophy of the villi could be found. When the 
mothers were diseased, the lesions were more complex. Follow- 
ing were his conclusions : 

1. There is syphilitic placenta, presenting characteristic 
features. 2. It is found only in cases of congenital or he- 
reditary foetal syphilis. 3. The seat of the lesion differs when 
the mother is affected from that when the virus is merely car- 
ried by the spermatozoa to the ovule. In a case like the latter, 
the placenta is dsgenerated, the foetus is diseased, the villi of the 
foetal placenta are filled with fat granules, while their vessels 
are obliterated and their epithelial coverings either thickened 
or absent. In case the mother is tainted, one of these con- 
ditions may be present : 1. If the mother is infected during the 
copulative act, syphilitic foci often develop in the maternal 
placenta. 2. If the mother is syphilitic before impregnation, 
or soon becomes so, the chances of the placenta being healthy 
are about even. 3. If the mother is not infected till she has 
passed the seventh month, both foetus and placenta escape. 4. 
Inoculation of the foetus during delivery has not been estab- 
lished. 

Apoplexy and Inflammation of the Placenta.— Hemor- 
rhage into the placenta sometimes takes place from congestion 
of the utero-pla cental vessels, proceeding from disturbances in 
the mother's vascular system. The extravasation may be into 
the placental parenchyma, into the serotina, or into the uterine 
sinuses. Extravasation is due mainly to morbid changes in 
the decidual vessels, often as the result of placentitis. The 
blood coagula undergo the ordinary retrogressive meta- 
morphoses. Occasionally cystic, fatty, or calcareous degenera- 
tion takes place. The hsematomata by pressure may interfere 
with proper nutrition of the foetus, and result in its death. 

Placentitis has been alluded to by some authors as a com- 
mon disease, and various pathological changes have been at- 
tributed to it, such as hepatizations, purulent deposits, and 
adhesions to the uterine structures. Its existence is now 
disputed by many, who contend that the morbid changes 
alluded to are due simply to retrogressive metamorphoses in 
coagula. "What has been taken for inflammation of the 



Pathology of the Ovum. 197 

placenta," says Kobin, "is nothing else than a condition of 
transformation of blood-clots at various periods. What has 
been regarded as pus is only fibrin in the course of disorganiza- 
tion, and in those cases where true pus has been found, the pus 
did not come from the placenta, but from an inflammation of 
the tissue of the uterine vessels, and an accidental deposition 
in the tissue of the placenta." Other writers affirm its ex- 
istence, and assign to it etiological relations with metritis and 
endometritis. According to their view the inflammation origi- 
nates in the serotina, or in the adventitia of the foetal arteries, 
generally producing granulation tissue, which, from contrac- 
tion, produces compression of the placental vessels, which, in 
turn, may result in their obliteration, and lead to fatty de- 
generation of the villi. Should the inflammatory action be 
recent, the friability of the new granulation tissue may result in 
retention of parts of the placenta. Placentitis is sometimes 
accompanied with hemorrhages which prove fatal to the foetus. 
It rarely results in suppuration. 

Hydramnios. — The chief pathological condition of the am- 
nion is that in which the liquor amnii exists in excessive quan- 
tity, known as hydramnios. This term should be restricted, 
however, to those cases in which the amount of fluid is so large 
that, by its pressure on the uterus, the abdominal or thoracic 
viscera, or the foetus, morbid symptoms are developed. Dr. 
Kidd limits the term to cases in which the amnion contains 
more than two quarts of the liquor amnii; while Charpentier 
says "All authors agree that when the quantity exceeds 32 or 
48 ounces, there is dropsy of the amnion." 

Signs and Symptoms.— These manifest themselves chiefly in 
the direction of overdistension of the uterus, the effects of which 
first become noticeable at the fifth or sixth month, when the 
abdominal development may be nearly as great as that of 
normal pregnancy, at full term. The distension ultimately be- 
comes so great that various distressing symptoms ensue, such 
as palpitation of the heart, dyspnoea, neuralgia and oedema of 
the labia and lower extremities, epigastric distress, dysuria, 
nervous disturbances and painful locomotion. The bowels are 
usually constipated, sleep is disturbed, the spirits are depressed, 
and, in some cases, delirium, and even eclampsia follow. 

In the latter part of gestation, under the influence of so great 
distension, the abdomen assumes a peculiar shape, which, how- 
ever, is mainly an exaggeration of the abdominal outline de- 



198 Pregnancy. 

scribed in the earlier part of this work. What we mean by this 
is, that the development is mainly in front, while the sides are 
relatively flattened. The outline of the uterus can easily be 
felt, there may be no marked evidence of fluctuation, though 
this is not a constant sign, while the walls are extremely tense. 
Foetal movements are indistinct, and sometimes unrecognizable. 
Vaginal ballottement cannot be successfully practiced in every 
instance, on account of the soft (edematous condition of the 
uterine tissues. Palpation of the overdistended abdominal 
walls is painful, and in some cases cannot be borne. 

Diagnosis. — In some cases of hydramnios, differentiation is 
attended with some difficulty. First of all, we should endeavor 
to recognize the existence of pregnancy, having done which, we 
will have to distinguish between several possible conditions, 
namely, twin pregnancy, ascites accompanying pregnancy, and 
ovarian dropsy associated with that condition. In uncompli- 
cated twin pregnancy, the form of the uterus would differ in the 
direction of lateral expansion and anterior flattening, while 
the sounds of the foetal heart would be heard. Fluid in the 
peritoneal cavity, again, would give rise to lateral expansion 
and fluctuation, while anteriorly the foetal outline would be felt. 
Ovarian dropsy, in association with pregnancy, is a rare com- 
plication, and might present some difficulties. However, the 
ovarian growth would be pushed to one side by the enlarged 
uterus, thereby giving to the abdomen an uncharacteristic ap- 
pearance. Foetal movements and the foetal outlines would be 
felt, and to both palpation and auscultation there would be evi- 
dence of lateral uterine displacement. The diagnosis of coex- 
istent hydramnios and ascites is difficult. Fluctuation would, 
perhaps, be felt all over the abdomen, but whether within or 
without the uterine cavity, is, at the moment, not easily de- 
termined. Fluctuation will be more distinct upon the sides, and 
the characteristic form of hydramnios alone, will be lost. Aid to 
diagnosis is afforded by the rhythmical contractions of the 
uterus, though they are felt less distinctly than in normal 
pregnancy. Vaginal examination will afford some evidence of 
an excess of amniotic fluid. 

Termination. — Premature expulsion of the foetus very often 
happens as the result of foetal death, of placental separation, 
or of overdistension of the uterus. The latter condition ren- 
ders uterine action feeble, and hence the first stage of labor is 
greatly prolonged. Should uterine inertia prevail in the third 



Pathology of the Ovum. 199 

stage, hemorrhage is liable to ensue. In general, however, upon 
rupture of the membranes and escape of the amniotic fluid, 
vigorous contractions ensue, and lead to precipitate expulsion. 
Involution is apt to be slow and imperfect. 

Prognosis. — In four cases out of thirty- three collected by 
McClintock, the women died after labor, the result being attrib- 
utable to their debilitated, state. Foetal mortality is very 
great. Nine of the thirty-three children were born dead, and 
ten died within a few hours. 

The Effect on Labor. — Even in those cases wherein the 
amniotic fluid is excessive in quantity, but still not sufficiently 
so to acquire the title of hydramnios, the effect on labor is to 
create feeble uterine action, and cause delay. The effect is more 
marked in the first stage of labor, since, at its close, the mem- 
branes usually break. 

Treatment.— For the disease itself no remedy has yet been 
found. Should the mother's condition become distressing and 
perilous, the physician will feel called upon, in the interest of 
his patient, to puncture the membranes and draw off the liquor 
amnii. Inasmuch, however, as this procedure is sure to be fol- 
lowed by foetal expulsion, it ought to be postponed as long as 
the woman's safety will permit. Play fair suggests the possi- 
bility of puncturing the membranes with a fine aspirator needle, 
and modifying the distension by drawing off the fluid only in 
part, thereby affording relief without bringing on premature 
labor. Disturbance of the mother's heart is one of the symp- 
toms most urgently calling for interference. If during labor 
the excessive distension of the uterus retard dilatation of the 
os, the membranes should be ruptured, and the amniotic fluid 
permitted to escape. The unusual danger of post-partum 
hemorrhage, which threatens in these cases, ought to be borne 
in mind, and the best precautions adopted. 

For such women, the homeopathic physician will think of 
antipsoric remedies, and will select those which, from special 
symptoms, seem best indicated. 

Deficiency of the Amniotic Fluid.— When the liquor amnii 
is deficient in quantity foetal movements are- restricted, and 
hence are liable to cause unusual pain to the mother. Direct 
pressure of the uterus on the foetus is liable to cause deformity. 
The amnion not being separated from the foetus in the early 
part of pregnancy, abnormal amniotic folds and adhesions 
between the amnion and foetus may form. Foetal deformity 



200 



Pregnancy. 



and intra-uterine amputation may result from mechanical com- 
pression by the foeto-amniotic bands thus formed. 

Anomalies of the Amniotic Fluid. — The amniotic liquor 
does not present constant characters. Instead of being limpid, 
and of an inoffensive odor, it may be thick and emit a dis- 
agreeable smell. The cause of these variations is not fully 
understood. 

Pathology of the Cord.— The average length of the cord is 
about twenty -two inches, but there are extreme variations, the 
maximum length being about one hundred and eight inches, 
and the minimum about three inches. When unusually long, 
the cord is liable to complicate pregnancy by becoming tightly 
drawn about the neck or limbs of the foetus. In this way intra- 

y — ^^_,_ uterine amputation 

is probably some- 
times performed, 
and by a similar 
process foetal life 
may be destroyed. 

Knots.— Knots of 
the umbilical cord 
are found once in 
two hundred cases. 
They are doubtless 
produced by the foetus in its movements passing through loops 
in the cord. Those formed during parturition are loose, and 
in any case, if there is the usual quantity of Wharton's gela- 
tine in the cord, little harm is likely to result from a knot 
made at such a time. When formed during pregnancy, their 
long continuance, and the consequent absorption of Wharton's 
gelatine occasionally produce fatal results. 

Torsion. — A certain amount of torsion is frequently ob- 
served, and without consequent evil results; but occasionally 
it is so extensive and strong as to destroy foetal life. It occurs 
most frequently about the middle of pregnancy. The arteries 
of the cord take a spiral direction about the umbilical vein, and 
this very arrangement serves as a protection to the circulation ; 
but a few twists are sufficient to interrupt it. Torsion is 
supposed to result from rotation of the foetus on its longitudi- 
nal axis, but whether it happens during foetal life, is a moot 
question. Martin claims to have demonstrated that the effect 
is not from active foetal movements, but is a post-mortem 




Figs. 113 and 114. — Knots of the Umbilical Cord, 



Pathology of the Ovum. 201 

occurrence. In support of this, Schauta advances the following 
propositions : 1. The large number of twists generally found 
indicate this, because any one of them is capable of producing 
foetal death. 2. It is improbable that the healthy cord can suffer 
such torsion, inasmuch as compensatory reverse rotation would 
be caused by its elasticity. 3. Twenty-five artificially-induced 
twists in the cord caused rupture. As high as three hundred 
and eighty torsions have been found in a single funis. 

Coiling of the Cord.— The umbilical cord is often found 
wound around the neck or other parts of the foetus. It is ob- 
served in one out of every eight or ten cases. As high as seven 
turns about the neck have been observed, though it is rare to 
find more than two. When rapidly formed they may lead to 
immediate death of the foetus. They are especially liable to 
complicate delivery. During descent of the child, the loops 




Fig. 115.— Torsion of the Cord. (Martin.) 

which were at first but moderately tight, are drawn upon, and 
thus strangulate the child before the complication is recognized 
and relief afforded. Strangulation probably occurs more 
slowly during intra-uterine life, owing to gradually increased 
tension of the coils. In this manner the foetal head has in some 
instances been nearly amputated. From shortening of the 
cord thus produced, there may result anomalous positions, 
premature separation of the placenta, retardation of labor, 
and even foetal death. 

Cysts of the Cord are sometimes observed. They are 
formed within the amnion, and are the result of liquefaction 
of the mucoid mass, or by accumulation of serum between the 
epithelial layers of the allantois. 

Hernia. — Protrusion of a loop of intestine into the umbilical 
cord, from errors in development, are occasionally met. In our 
own practice we have encountered the condition but once. 



202 Pregnancy. 

Hernia may occur in otherwise well-developed foetuses, but it is 
frequently associated with other deformities, such as stricture 
of the rectum, imperforate anus, distortion of the lower limbs 
or of the genitals, resulting, in the main, from traction of the dis- 
placed viscera on adjoining parts. The hernial sac is composed 
of the amnion and the peritoneum, and its contents are con- 
volutions of the intestines, though other organs are sometimes 
included to such an extent as to leave the abdomen nearly 
empty. 

Calcareous Deposits have been found in the cords of foetuses 
presenting evidences of syphilis. 

Stenosis of the Vessels.— Atheroma, and consequent 
thrombosis, have been known to give rise to stenosis of the 
umbilical arteries. In syphilitic foetuses, chronic phlebitis, with 
the new connective tissue developed in connection with it, may 
produce stenosis of the umbilical vein, and occasionally of the 
arteries. 

Anomalous Insertion. — Anomalies in the distribution of the 
vessels of the cord are often met. The insertion may be into 
the margin instead of the center of the placenta, and then the 
latter organ is known as battledore placenta. The cord is 
sometimes found to separate before reaching the placenta and 
spread its vessels on the membranes, in which case it is known 
as insertio valamentosa. 

Pathology of the Foetus.— Comparatively little is known 
of the diseases to which the foetus is liable, but enough has been 
observed to teach us that it may suffer from nearly as great a 
variety of pathological states as the young child. Death of 
the foetus is in such a manner often compassed. Following are 
some of the ailments which are known to attack the unborn : 

Inflammations of various parts have been known to exist, 
the peritoneum being a common seat of attack. The pleura 
and lungs have often been found involved. 

Fevers are transmitted from the mother, and the foetus 
doubtless at times becomes idiopathically their subject. When 
the mother suffers from smallpox, she usually miscarries, and 
the foetus is most commonly observed to be infected. 

Syphilis is a disease from which the foetus does not escape. 
Premature labor and foetal death are common results of the 
affection. The evidences of involvement of the offspring are 
not always patent at birth, but a careful examination post- 
partum, or a thoughtful consideration of the symptoms subse- 



Pathology of the Ovum. 203 

quently developed, in living children, discloses the true disturb- 
ing cause. 

The sensitiveness of the foetus to certain poisons is shown in 
the numerous reports of lead and malarial poisoning. M. Paul 
collected eighty-one cases in which there was evidence in dead 
foetuses of the toxical effects of lead. In some instances the 
foetus was affected while the mother escaped. 

Among dropsies, hydrocephalus is the most frequent, but 
not the only, form met. The fluid distends the ventricles, and, 
as a result, there is expansion and thinning of the cranium, the 
bones of which are widely spread. Ascites and hydrothorax 
are now and then met. The following foetal diseases, among 
others, have been reported : Pleurisy, scirrhus, tubercles, pneu- 
monia, calcareous deposits, peritonitis, scarlatina, measles, 
enteritis, worms, calculus, jaundice, rickets, caries, necrosis, con- 
vulsions, hemorrhages, etc. Tumors of various kinds, and in 
different situations, have been observed. Tarnier reported a 
meningocele larger than a child's head, and large cystic growths 
have been found attached to the nates, thorax and other parts. 

The child may suffer from the effects of violence. Extensive 
lacerations, and contusions in various parts of the body, have 
been observed. Intra-uterine fractures have resulted from 
injuries, but there is no doubt that spontaneous fractures do 
occur, and are nearly always multiple in the same foetus. 
Chaussier speaks of a child born in 1803, after a rapid and easy 
labor, who had forty-three fractures, even the cranial bones 
being involved. He also reports a case in which a child was 
born after an extremely short and easy labor, presenting feeble 
signs of life, and living but a short time, upon whom were 
found one hundred and thirteen fractures. The causes of such 
anomalies are not well understood, but are supposed to be due 
to arrested development of the bony structures. 

Intra-uterine Amputations.— Another phenomenon equal- 
ly remarkable, is that of amputation of foetal extremities. 
Numerous cases of limbs deprived of a portion of their con- 
tinuity have been reported, in which the stump presented 
evidences of traumatism. Medical records show cases in which 
the whole four extremities were wanting, as shown in figure 116. 

The cause of these conditions merits much attention. Such 
amputations are commonly explained by assuming that they 
are the results of gangrene ; but Reuss holds a different view. 
It does seem that the gangrene theory is untenable, inas- 



204 



Pregnancy. 



much as such a degenerative change cannot take place in the 
absence of atmospheric air, though there may be an equally 
destructive process. 

A certain number of these amputations probably result 
from coiling of the cord about the extremities ; and another 
of the most common causes is the constriction of fibrous 
bands or folds of the amnion. But in many instances none of 

these causes have been 
at work, and hence their 
etiology is shrouded in 
obscurity. 

Foetuses who suffer 
intra-uterine amputa- 
tion are usually still- 
born. 

The amputated part 
is sometimes found lying 
in the amniotic cavity, 
and follows the child in 
delivery. More frequent- 
ly the amputated por- 
tion disintegrates and 
disappears. But this 
can occur only when 
amputation has taken 
place at an early period 
of development. When 
separation is effected at 
a later period, the part is 
not only found, but cica- 
trization of the stump is 

often incomplete. Rudi- 
Fig. 116. — Intra-uterine Amputations. , . ~ -. 

mentary toes are found 

on the stump, which are believed by some to be abortive at- 
tempts of nature at reproduction of the lost parts. 

Monstrosities.— Deviation from the ordinary process of de- 
velopment results in the production of monsters. The subject is 
one which might very properly here be considered at length, but 
it is so extensive that we shall attempt to give only its outlines. 

Our observation in this direction has been very limited, and 
we follow Charpentier, who, in turn, quotes mainly from Saint- 
Hilaire. 




Pathology of the Ovum. 



205 



Monsters are divided into two grand classes, namely, simple 
and composite ; the former being made up of elements of a 
single foetus, and the latter of elements of more than one. 

Simple Monstehs. — In these there is either absence of indi- 
vidual elements, or unnatural distribution of them. They have 
been divided into three varieties, namely, autosites, ompha- 
losites and parasites. The first are capable of sustaining life 
for a time after birth; the second can live only in the uterus; 
and the third are morbid productions, having their seat either 
in the uterus or ovaries. 

Autosites have been divided again into varieties according 
to the character and seat of the abnormal development. Ectro- 
melic foetuses are such as lack one or 
more limbs, but do not include cases 
of intra-uterine amputation. Pho- 
comeles are those wherein atrophy is 
limited to the middle segments of the 
limbs, the feet and hands being well 
developed. Hemimeles are foetuses 
with rudimentary feet, hands, and 
forearms or legs. Ectromeles are 
those wherein arrested development 
includes all the segments to about an 
equal degree. In symmelic foetuses 
there is a union of two limbs of the 
same kind. They are symmelic when 
the fused legs have only one foot. 
Sirenomeles are where the fused limbs Fig. 117.— Acephalic Foetus, 
terminate in a point without a foot. Celosomic foetuses have 
more or less complex eventration of the genito-urinary organs 
and various viscera. These are given various names according 
to the character of the abnormality. 

Exeneephalic foetuses are characterized by badly formed 
brains which are only partly enclosed by the skull. They are 
divided into notencephalic, proencephalic, podencephalic, hy- 
perencephalic, iniencephalic. Exeneephalic foetuses are charac- 
terized by the presence of the brain almost entirely outside the 
skull. Pseuden cephalic foetuses are entirely wanting in brain 
matter. The vault of the skull is absent. The superimposed 
mass is small, of a deep red color, provided with interlacing 
vessels, separated only by debris of brain matter. Anence- 
phalic foetuses differ from the last named mainlv in the absence 




206 Pregnancy. 

of the fungoid tumor. There is arrest of development through- 
out the entire vertebral canal. Derencephalic foetuses differ from 
the anencephalic in the absence of so extensive a fissure of the 
vertebral canal. 

Cyclocephalic foetuses are anomalous in the absence of nasal 
appendages, and in misshaped eyes. These are often associated 
with other abnormalities. Five varieties have been described : 
ethnocephalic, cebocephalic, rhinocephalic, cyclocephalic (true), 
stomocephalic. 

Octocephalic foetuses— These are derivatives of the cyclo- 
cephalic, with more marked tendency to atrophy. Their most 
characteristic feature is an approximation of the ears. Five 
varieties are described: sphenocephalie, octocephalic, edoce- 
phalic, opocephalic and triocephalic. 

Omphalosites. — There are many varieties of these, and, in 
view of their variety, but a brief mention will be made of them. 
Paracephalic foetuses are those in which the characteristic 
feature is the head, which is only a mass at the upper part of 
the trunk. Acephalic foetuses have no head, but a mere anatom- 
ical trace of it. Anidic foetuses have sometimes been called 
acardiac. They constitute almost an indeterminate mass of 
varying form. They are termed parasitic. 

Composite Monsters. — There are many varieties of these. 
They are twins practically complete, with separate organic ac- 
tion, but with united bodies. When joined back to back, they 
are called pygopagi ; when united by the heads and look in the 
same direction, they are termed metopagi; and when joined 
head to head, but facing in opposite directions, they are known 
as cephalopagi. Monomphalic foetuses are united at the 
trunkal surfaces, and present the following varieties : xipho- 
page, sternopage, ectopage and hemipage. 

Sycephalic Foetuses.— In these there is fusion of the heads. 
They are always of the same sex. Following are the varieties : 
janiceps, myopes and synotes. 

Monocephalic Foetuses are those in which one head, without 
trace of union, surmounts two bodies. 

Deradelphe — In these the bodies are united above the umbili- 
cus, and separated below. If there are four pelvic limbs and 
two thoracic, the monstrosity is termed thoradelphe. Iliodelphe 
are those with one head and neck, two thoracic limbs, one body 
below the umbilicus, and four pelvic limbs. Synadelphe are 
those with one head, single trunk, four arms and four legs. 



Pathology of the Ovum. 



207 



Sysomic Foetuses.— hi these there is fusion of the two trunks, 
but the heads are not involved. Psodymes have a single pelvis 
and two lower limbs. Xyphodymes have a fusion involving 
likewise the lower part of the thorax. In derodymes fusion of 
the bodies is throughout the entire 
length. 

Monosomic Foetuses.— -In these 
there are two heads upon a single 
body. The varieties are, atlo- 
dymes, miodymes and opodymes. 

Complex Parasitic Monstrosi- 
ties.— Here there is fusion of two 
beings, but one has undergone such 
arrest of development that it could 
not sustain independent existence. 
They are exceedingly rare in the 
human species, and do not deserve 
extensive mention in a work of this 
character. Among the varieties are 
heteropage, heterodelph, hetero- 
dyne, heterolicus, polygnathus, 
epignathus, hypognathus, aug- 
nathus, pygomelus, gastromelus, 
cephalomelus and melomelus. 

Death and Retention of the Fcetes.— Expulsion of the 
foetus does not, in all cases, immediately follow death. If the 
placenta does not separate from the uterus, its vitality may 
remain, its development continue, and expulsion thus be de- 
layed. When the 
placenta does be- 
come separated, 
whether as cause 
or effect of fcetal 
death, retention is 
probably due to 
diminished irrita- 
bilitv of the reflex Figs. 119 and 120. — Monosomata. (Charpentier.) 

nervous centers which preside over the uterine energies. Re- 
tention due to uninterrupted utero-placental relations, is rarely 
prolonged beyond the ordinary period of utero-gestation, 
while retention referable to diminished reflex irritability may 
be indefinitely protracted. 




Fig. 118.— Pygopagi. (Chi 
pentier.) 





208 Pregnancy, 

When the foetus is retained, and the membranes continue 
intact, the most important changes are mummification, macera- 
tion, and calcification. If the membranes are broken before 
or soon after foetal death, mummification may result, or cal- 
careous degeneration follow. If air gains entrance into the 
uterine cavity, putrefactive changes are apt to take place. 
Mummification having begun, putrefaction does not set in. 

Putrefaction. — This cannot take place unless air finds 
entrance to the uterine cavity. The conditions then met 
are those most favorable to its development, namely, mois- 
ture and heat. It often proceeds with great rapidity, so 
that surprising changes occur within a few hours. McClintock 
says he has observed the abdomen become quite tympanitic be- 
fore delivery in cases where death did not occur until after the 
beginning of labor. The changes resemble those which take 
place in the body of a person who has drow T ned : i. e., the abdo- 
men swells with gas, the deeper tissues of the body become 
cedematous, the emphysematous connective tissue crepitates 
when pinched, and a horrible odor is emitted from the body. 
Sometimes the uterus becomes distended by the gas generated 
in the process of decomposition, emitting it at intervals, which 
condition is known as physometm. The woman suffers chilli- 
ness, elevated temperature, and a sense of general illness, and, 
unless relieved from the source of infection, the process may 
terminate in death. 

Mummification.— -It becomes necessary to explain what is 
meant by mummification, and what are its causes. "At the 
second period of intra-uterine life is a particular change, entirely 
distinct in form from those which precede or which follow. The 
embryo, endowed with greater force of resistance, provided 
with an osseous frame, frail and incomplete, it is true, but 
nevertheless solid, composed of newly organized elements, which 
already have a fixed texture, does not liquefy; it preserves its 
first form, except its volume, which suffers a proportional re- 
duction. This is mummification, withering, emaciation, con- 
traction, drying up of the authors. The tissues, yet soft, are 
condensed under the influence of the prolonged maceration in a 
saline fluid; they are diminished in volume, reduced to a thinner 
layer, in a word, shrivelled up. The color also changes very 
rapidly ; it becomes dull, gray, yellowish, tarnished, and as if 
cachectic, contrasting clearly with the normal color, a brilliant 
dark rose. The quantity of sanguineous fluid exuded into the 



Pathology of the Ovum. 209 

different serous cavities is very small, very dark, and the rose 
color of the eye-humors hardly marked." 

It is most frequently observed in foetuses with inadequate 
blood-supply, a condition growing out of constriction of the 
umbilical cord. From preference, it attacks those dying during 
the middle stages of gestation, and especially a single foetus in 
twin pregnancy. When one mummified and one living foetus 
occupy the uterine cavity, gestation usually preserves a toler- 
ably normal course and expulsion of the living and the dead is 
deferred until the close of the ordinary period of utero-gestation. 

Maceration. — This is a process of slow decomposition, and 
by it an embryo may be entirely dissolved. A foetus, on the 
contrary, preserves the outline of its organs and general form, 
but granular degeneration and disintegration of its anatom- 
ical elements takes place. The epidermis first yields to the 
process. It rises in the form of blebs or vesicles, which fill with 
a reddish, sero-sanguinolent, or clear serous fluid. There is 
also infiltration of the corium, which has a brownish-red ap- 
pearance resembling the lees of wine. The subcutaneous areolar 
and adipose tissues are also oedematous. There is no odor, no 
gas, no cadaveric tint, and the process never gives rise to septic 
symptoms in the mother. Viewing the body as a whole, it is 
observed to be flaccid, and, from its oedematous condition, may 
be molded by pressure into grotesque shapes. (Edema is most 
apparent over the cranium, abdomen, feet, hands and sternum. 
The cranial sutures are separated, the articular surfaces pushed 
apart, and the periosteum is detached from the long bones. 
Dark blood is found in the vessels, and bloody serum in the serous 
cavities. The brain is pulpified, and all the viscera are softened. 

Moles.— Of these, one variety — the hydatidiform — has al- 
ready been described, and of the other varieties, but a brief con- 
sideration will be required. Moles have been divided into two 
general classes, one of w T hich is termed false, and the other true, 
the element of distinction between them being that the true 
mole is always consecutive on impregnation, and the false is 
not. Hence, in a work of this character and scope, we shall 
consider the former class only. 

True moles are divided into three general varieties, namely : 
1. The mole of abortion, or the blighted ovum. 2. The carne- 
ous, or fleshy mole; and 3. The hydatidiform mole. The last 
of these having been described, the first two varieties only re- 
main for consideration. 

(14) 



210 Pregnancy. 

The Mole of Abortion, or mola sanguinosa, is the blighted 
ovum, within which post-mortem changes have just begun, and 
the mass has not yet been materially altered, save in the direc- 
tion of extravasation of blood and dissolution of the embryo, 
whose vital resistance, until death, had been sufficiently potent 
to preserve its integrity. Many years ago Smellietook occasion 
to say that ''should the embryo die (suppose in the first or 
second month), some days before the ovum is discharged, it 
will sometimes be entirely dissolved, so that when the secun- 
dines are delivered there's nothing more to be seen. In the first 
month the embryo is so small and tender that the dissolution 
will be performed in twelve hours ; in the second month, two, 
three, or four days will suffice for this purpose." In case foetal 
death occurs in more advanced pregnancy, degenerative and 
disintegrative changes are wrought in a relatively short period, 
and the mass, when expelled, may not disclose its real character 
except to closest scrutiny. 

The Fleshy Mole. — The conditions which give rise to the forma- 
tion of the carneous mole are substantially as follow : As the 
result of some sudden or violent exertion, one or more blood- 
vessels give way, and as the blood is extra vasated, it acts in a 
mechanical way to influence separation of contiguous parts, 
with most potent results. The embryo perishes from want of 
nutritive supplies. A similar effect may be produced by apo- 
plexy of the placenta, elsewhere considered. Extravasation is 
sometimes between the chorion and decidua, and even within 
the amniotic cavity, and results in embryonic death. 

Consecutive on such occurrences there is, most frequently, 
speedy expulsion of the ovum, but occasionally it remains for a 
considerable time, and undergoes certain changes by which it is 
converted into a fleshy mass. The effused blood becomes decol- 
orized, the blanching proceeding from center to circumference, 
and, according to Scanzoni, the fibrin is transformed into cellu- 
lar tissue, by which means communication is established be 
tween the external lining of the ovum and the uterine tissues, — 
and thus further development is made possible. It is highly 
probable that complete separation of the ovum from the uterus 
never takes place in these cases, but, through the adherent 
parts, vascular communication is continued and amplified. De- 
generative changes take place chiefly in the decidua vera, though 
the chorion and amnion are sometimes more or less involved. 

These masses seldom exceed an orange in size, but their full 



Pathology of the Ovum. 211 

development, from the very nature of the case, is quite rapidly 
accomplished. They may continue in utero for three or four 
months, but eventually the organ is excited to contraction, and 
expulsion takes place, unattended, as a rule, by any remarkable 
symptoms. 

Little need be said with reference to the treatment of such 
cases. There are a few remedies which have the reputation of 
promoting the expulsion of moles, but whether the reputation 
has been fairty earned is a matter which we have not thus far 
been able to determine. The truth is, that, apart from the 
hydatidiform mole, which was previously considered, these de- 
generate products of conception are not often recognized, and 
hence women who are the subjects of them rarely fall under 
treatment until the process of expulsion is well under way. 
When uterine efforts at expulsion have once strongly set in, the 
form of promotive treatment, described under the head of abor- 
tion, is then applicable. We should use such means, whether 
they be fingers, instruments or drugs, as will safely hasten the 
process. For specific indications we refer to the chapter on 
abortion. If, from the symptoms, we should be led to believe 
that the uterus contains a mole, we may safely, and effectually, 
resort to such remedies as calcarea carb./silicea, sulphur, sepia, 
caulophyllum, sabina, secale, and sometimes others, according 
to specific indications. 



212 Pregnancy. 



CHAPTER X. 

DISEASES AND ACCIDENTS OF PREGNANCY. 

When we reflect upon the profound impressions made on the 
female organism, and the extensive changes wrought in it by 
pregnancy ; and furthermore, when we recollect that this con- 
dition exempts a woman from few of the ordinary ills of life, 
we shall cease to wonder that there is a pathological, as well 
as psychological, side to the subject. 

The Hygiene of Pregnancy.— At the risk of transposing 
the conventional order of discussing pathological states, we 
have chosen, at this point, to offer a few observations on the 
general management of pregnant women. 

The general health is frequently already disturbed, and the 
system in an enfeebled state, when pregnancy is established. 
The woman at once enters on the trying experiences of early 
gestation, and, attributing nearly all her symptoms to the 
physiological changes being wrought in her organism, viewing 
them also as in great measure essential features of her con- 
dition, she is prone to neglect proper attention to hygienic 
rubs. Though the advent of pregnancy find her in excellent 
health, she is extremely liable, while under the influence of sub- 
sequent ill-feeling, to neglect proper precaution in the way of 
attention to sanitary details which would materially mitigate 
existing suffering, and aid in preparing her for an easy and safe 
termination of gestation. 

We have seen many women so overcome by the nervous dis- 
turbances and gastric ailments of the early part of preg- 
nancy, as to seek close confinement at home, and sometimes 
even to take to their beds. This, of course, is altogether wrong. 
At that very time, fresh air and moderate exercise are of the 
greatest value. Those who spend their days mainly in the open 
air, and their nights in well -ventilated rooms, are tided over the 
distressful weeks of pregnancy in greater comfort than those 
who pay no regard to such sanitary essentials. Throughout 
pregnancy a woman ought to spend as much of her time in the 
open air, without walking or riding to the extent of produc- 
ing excessive fatigue, as the condition of the weather will per- 
mit. The health and strength of both mother and child are 
greatly promoted by so doing. 



Hygiene. 213 

The diet should be regulated to suit the peculiar require- 
ments and sensibilities of the woman, and ought to embrace 
most nutritious and easily-digested articles of food. It is not 
our purpose to give a complete bill of fare, but to indicate cer- 
tain articles which most commonly agree with the requirements 
and the peculiar sensibilities of women under these trying cir- 
cumstances. Patients are differently constituted, and have 
been so variously trained with respect to gastronomies, that 
many will prove heedless of our best advice, even though made 
emphatic. Some of them assume that it is a matter of no con- 
sequence what they eat, while others have derived from their 
friends or relatives certain harmful notions which they do not 
care to give up. 

Certain articles of food are peculiarly suited to the condi- 
tions which prevail in the early part of pregnancy which would 
be liable to disagree in late gestation. In the early weeks the 
gastric symptoms are chiefly nausea and vomiting; while in the 
latter weeks they are mainly those growing out of compression 
and a changed character of the gastric secretions. During the 
early period, unless the stomach is unusually sensitive, women 
may choose their food from among the following articles: 
mutton-broth, chicken-broth, oysters, clams and fish. When 
they have theretofore agreed, the following may also be eaten : 
beef, mutton, chicken, game, eggs, stale bread, oat meal, rice, 
baked potatoes, spinach, macaroni, greens, celery, green peas, 
lettuce, asparagus, oranges, grapes, and stewed fruit. Desserts 
should, in most instances, be avoided. 

There are doubtless many harmless things not included in 
this list, while, on the other hand, many of those which do ap- 
pear will not in all cases prove innocuous. In late pregnancy, 
as we have before said, compression and a changed character of 
the secretions constitute the most distressing factors of the 
gastric symptoms, and the diet should be modified to meet ex- 
isting conditions. Very likely the upward pressure of the 
enlarged uterus, in interfering with proper action of the 
stomach, and sometimes even changing its form, has much to 
do with the woman's discomfort. But even here, careful atten- 
tion to diet will go a long way towards relief. At this period, 
all articles of food which will increase the fermentative action 
so easily set up, ought to be avoided. Such are mainly those 
containing starch, sugar and fat. Some patients derive con- 
siderable benefit from indulgence in lettuce. Aerated bread, in 



214 Pregnancy. 

preference to all other, ought to be eaten. In considering 
various pathological states to which the pregnant woman is 
liable, we may have occasion to say something further on this 
subject. 

The pregnant woman requires not only an abundance of 
fresh air and good food, but also a certain amount of physical 
exercise. It must not be violent, nor carried to the production 
of excessive fatigue, as thus only shall we build up rather than de- 
stroy the best effects. Walking in the open air and riding in 
an easy vehicle, are conducive to good digestion and refresh- 
ing sleep. Although it is not commonly recommended, we 
truly believe, that carefully regulated calisthenics are decidedly 
beneficial. These ought to include breathing exercises, in which 
abdominal respiration is employed but not overdone. In this 
w T ay all the muscles of the body can be invigorated and pre- 
pared to do good service in the propulsive efforts of labor. By 
abdominal respiration the abdominal muscles are given 
strength and tone which they will not otherwise acquire,— an 
important consideration, as we can see w T hen we recall the part 
these structures play in the propulsive act. In women who 
have menstruated with regularity, it is well to regulate physical 
exercise so that it will not be excessive at what would be the 
menstrual period but for the interruption occasioned by preg- 
nancy. This precaution derives special emphasis from the 
peculiar proneness to miscarriage at the completion of 
monthly cycles. 

Sexual indulgence, always moderate, ought, during preg- 
nancy, to be interdicted at the recurrence of these periods. 

The free but judicious use of water is beneficial. Frequent 
sponge baths, followed by brisk rubbing, contribute to the 
vigor and tone of the general system. They should be taken in 
a warm room, and, in case of feeble women, ought to be given 
by an attendant. The vaginal douche may be employed, but 
the stream should be feeble and the quantity of water mod- 
erate. 

The mind of the pregnant woman deserves even more atten- 
tion than the body. It is highly important that her surround- 
ings be of the most agreeable nature, and the mind thus 
maintained in the greatest possible state of tranquillity. When 
left to herself she is very apt to fall into morbid moods, and, at 
times, to suffer distressing mental perturbation. It lies upon 
the physician and the friends of the woman, as an obligation, 



Diseases and Accidents. 215 

to show her the bright side of life, and to maintain a cheerful 
and hopeful spirit. Primigravidae are often astonished to find 
labor so painful. It is to them a revelation, but a revelation 
which should not be made in advance. "Sufficient unto the 
day is the evil thereof.'' It is far better to fill the mind of the 
pregnant woman with bright images and agreeable prospects, 
since by such management the tedium of gestation becomes far 
more bearable, and the outcome much less distressful. If possible, 
prevent her from being brought into contact with women who 
take exquisite delight in harrowing the souls of unsophisticated 
young married women just entering upon maternity with a re- 
cital of the perils and suffering which await them at parturition. 
If despite the most judicious management our patients in early 
and middle pregnancy do become depressed and disheartened, 
they may be indulged in a pleasant trip by rail or other easy 
conveyance, to home or friends, and thereby, for a time, be 
gotten out of the monotonous cycles of ordinary domestic 
life. 

The entire period of utero-gestation to some women is one 
of physical and mental distress, and from it they finally emerge 
with a sense of joy akin to that experienced by the prisoner 
who is set free after long confinement. The ailments from which 
they suffer are various, oftentimes relievable by medication, or 
a change of scenery ; while in certain instances they cannot be 
made to give way , though every intelligent effort be put forth to 
subdue them. 

Urinary Tests. — At varying intervals in the latter part of 
pregnancy careful tests of the urine ought to be made, both as 
to quantity and constituents. Diminution of the diurnal ex- 
cretion usually precedes albuminuria. Various conditions, 
among which are atmospheric temperature and the amount of 
fluids drunk, have an important bearing on the quantity of 
urine voided, and these should be given due consideration. The 
presence of any albumen, or a diminution of the quantity of 
urea much below 500 grains, in a woman weighing 140 pounds, 
should be regarded with suspicion. 

Derangements of the Digestive System.— The most 
prominent derangements of the digestive functions, referable 
chiefly to sympathetic irritation, are nausea and vomiting. 
They are the common accompaniments of pregnancy, and un- 
der ordinary circumstances can hardly be considered as ailments 
requiring medical attention ; but occasionally they are so ex- 



216 Pregnancy. 

cessive and long continued as to lead to inanition, extreme 
debility, and even death. Veit attributes the uncontrollable 
vomiting of pregnancy in many cases to endometritis. In some 
cases the sickness is limited to the morning hours, at which 
time the smallest quantity of food is rejected, while later in the 
day it may be borne with impunity. From these circumstances 
the nausea and vomiting of pregnancy have been designated 
" morning sickness." In other cases, the woman feels constantly 
sick, and the mere smell of food may bring on a paroxysm of 
vomiting. 

These distressing accompaniments of pregnancy are not 
experienced by all women, but about forty per cent, of them 
escape such disturbance altogether. They usually begin about the 
sixth week, and continue till the close of the third month. Some- 
times, however, they immediately follow conception, and con- 
tinue until the end of pregnancy, while in other women they do 
not appear until the patient has reached the latter months of 
gestation. 

It is surprising to observe how severe and protracted may 
be such gastric disturbances in some cases without producing 
emaciation or excessive debility, while in other instances the 
vital forces are thereby brought to a low ebb. Grave cases are 
characterized by a dry coated tongue, pallor and distress of 
countenance, excessive nervous irritability, tenderness of the 
epigastrium, great restlessness, and general heat. In worse 
cases there is elevated temperature, with rapid, small and 
thready pulse. Want of nourishment soon reduces the woman 
to a state of extreme emaciation. The breath becomes foefcid, 
and the tongue dry and black. Profound exhaustion, with 
low delirium, follows, and, in the absence of relief, death soon 
ensues. 

The prognosis in nausea and vomiting of pregnancy, though 
the affection should assume a grave form, is generally hopeful; 
but such cases create much anxiety. Gueniot collected 118 
cases of this form of the disease, out of which forty-six died ; 
and out of the seventy-two who recovered, in forty-two the 
symptoms ceased only when abortion, either spontaneously 
or artificially induced, had occurred. Upon the termination 
of pregnancy the symptoms sometimes at once disappear, and 
the digestive and assimilative processes soon become active 
and vigorous. 

Treatment.— It is of prime importance to regulate the diet 



Diseases and Accidents. 217 

of women suffering from morning sickness. A few niouthfuls 
of food, or a cup of coffee, taken in the morning before rising, 
many times proves of decided benefit. Food should be taken 
in small quantities and at short intervals. Ice cream thus 
eaten will sometimes be retained when nothing else can be. 
Koumyss, when fancied by the patient, is a remarkably good 
food. Special articles can be selected from the list given under 
the head of the Hygiene of Pregnancy. The woman's caprices 
should be considered in the choice of food, but should not be 
allowed to betray one into injudicious selections. The bowels 
ought, throughout pregnancy, to be kept open. 

In some cases, where other forms of treatment prove una- 
vailing, and the patients are greatly reduced, a change of habi- 
tation, air and scenery, especially from a poorly ventilated 
house in the crowded part of the city to a rural situation, is of 
the greatest benefit. 

Since it is clear that the nausea and vomiting of pregnancy 
are mainly dependent upon changes going on in and about the 
uterus, the attempt has been made to reduce the irritability of 
the organ by local treatment. Morphia, in the form of supposi- 
tories, and belladonna applications to the cervix, have been 
recommended, the former being in some cases of apparent 
benefit. The cervix has been burned Avith caustic, and bitten by 
leeches, in the vain endeavor to overcome the obstinate sick- 
ness. In the latter months, gentle dilatation of the cervical 
canal to a slight degree only, has been attended with beneficial 
results. Dr. Grailey Hewitt believes that in quite a large per- 
centage of cases the disorder depends on uterine deviations, and 
can be cured only by their rectification. This may be true and 
the suggestion should lead to a careful examination in all ob- 
stinate cases. If retroverted, a Hodge, or an Albert Smith 
pessary, properly adjusted, can be safely worn. During the 
employment of local treatment a woman should be required to 
rest more than usual in the reclining posture. 

Galvanism, in some cases, has afforded relief to distressing 
nausea and vomiting. The current ought not to be directed 
through the uterus, but one pole may lie on the epigastrium and 
the other on the nape of the neck. 

Ether spray upon the epigastrium will in some instances decid- 
edly allay these distressing symptoms. 

Production of vesication over the fourth and fifth dorsal 
vertebrae will often afford great relief. The same may be said 



218 Pregnancy. 

of the glycerine tampon, and of the well-fitted abdominal sup- 
porter. 

The list of remedies which may be found useful in this condition 
is long, but there are a few especially prominent. 

Ipecac should be given when the nausea is the predominant 
symptom attended with vomiting of bilious matters, undigested 
food, and large quantities of mucus. 

Arsenicum, when the vomiting occurs after eating and drink- 
ing, and there is faintness, and excessive prostration of the 
vital forces. 

Nux vomica, for real morning sickness ; bitter, sour eructa- 
tions ; vomiting of sour mucus and the ingesta. Also, for ex- 
cessive nausea, with the feeling that she would be better if she 
could vomit. 

Tabacum, in those cases where there is nausea, with faint- 
ness and deathly pallor, relieved by being in the open air. 
Vomiting of water, acid fluid and mucus. 

Psorinum is suited to obstinate cases, especially in women 
presenting the psoric diathesis. 

Pulsatilla, especially when the vomiting comes on in the 
evening or night. The appetite is capricious, the woman crav- 
ing beer, acids, wines, etc. Much eructation tasting of the 
ingesta. Specially suited to mild, tearful women. 

Acetic acid, when there is sour belching and vomiting, with 
profuse water-brash and salivation. 

Colchicum, when the following symptom is well marked : ex- 
cessive nausea, even to faintness, produced by the odor of fish, 
eggs, meat, etc. 

Bryonia, when the nausea and vomiting are brought on or 
decidedly aggravated by the least motion. Veratrum album is 
well suited to the same symptom. 

Phosphoric acid, a few drops of the dilute acid in a half glass 
of water, and a teaspoonful every two hours, is often of the 
greatest service. Its special indications correspond pretty 
closely with those given above for acetic acid. 

Sulphur. — Nausea, without vomiting, with faint sickish 
spells during the forenoon. 

Almost every remedy in the materia medica has been recom- 
mended, and we doubt not that there are cases to which they 
are severally suited. 

Hyperemesis. — When the vomiting is absolutely uncon- 
trollable — as it will rarely prove to be when the patient fully 



Diseases and Accidents. 219 

co-operates with her physician in the effort at cure — and fatal 
results seem imminent, there remains as an ultimate resource, 
the artificial interruption of pregnancy. In considering this ex- 
pedient regard should be had for the clinical fact that, in most 
instances, the threatening symptoms disappear at about the 
close of the third month. It is an operation which is liable to 
subject the physician to criticism, and, as it is attended with 
considerable risk, it should never be undertaken upon the re- 
sponsibility of a single attendant. 

There seems to be no doubt that some mothers have been 
saved by the induction of abortion in such cases, in all proba- 
bility many have been lost for want of it, while some probably 
owe their death to it. The success of the operation demands 
that it be performed before prostration has become so great 
that the patient cannot rally. The obvious indication is to 
diminish uterine tension, without delay, and the preferable 
mode of doing this is to puncture the membranes with a uterine 
sound or stiff catheter, and allow the amniotic fluid to escape. 

Prof. C. Braun, of Vienna, reports a case of hyperemesis to 
which he was called, in which the woman was supposed to be 
moribund. The physician in charge had resolved on the induc- 
tion of premature labor as a last resort. Dr. Braun decided to 
bathe the intra-vaginal portion of the cervix in a ten per cent, 
solution of nitrate of silver. This was done and the surface 
quickly dried to prevent further cauterization. An hour after- 
wards the patient enjoyed and retained a meal of roast beef 
and there was no subsequent vomiting. 

Braun says he has never, in all his vast obstetrical practice, 
seen a case of death from hyperemesis. In an obstetrical ex- 
perience extending over a period of fourteen years, we have 
never seen a case in which the symptoms became so uncontrolla- 
ble as to cause us seriously to think of this operation. Further- 
more, we believe that homeopathic literature will show very 
few cases wherein the induction of abortion became necessary 
in order to control nausea and vomiting. In France, where 
abortion is frequently induced for the relief of these symptoms, 
the vomiting is arrested in only about forty per cent, of all 
cases, while ten per pent, of them terminate fatally. 

Other Gastric Disorders.— Anorexia, or want of appetite, 
and even a loathing and disgust for food, is a prominent dis- 
order of the stomach, especially during the early months of 
gestation, but, under the influence of gentle exercise, pure air, 



220 Pregnancy. 

salubrious surroundings, and judicious selection of food, it will 
generally disappear. The remedies which are most likely to 
afford aid are the following: 

Nux vomica, when there is irritability of temper ; exceeding 
sensitiveness to every impression, and constipation with fre- 
quent ineffectual urging to stool. 

Ipecac when associated with distressing nausea, with, or 
without, vomiting. 

Antimonium tartaricum affords help when there are vomit- 
ing of mucus, sense of weakness, bad humor and pale face. 

Antimonium crudem is the remedy when there are white 
tongue, unusual activity of the muciparous glands in various 
parts, and no thirst. This remedy is pre-eminently suited to 
women who have gastric catarrh. 

Colchicum, with its strong characteristic of extreme aversion 
to the odor, or even the mention, of food, is an excellent 
remedy. There is no thirst 

Other remedies are natrum muriaticum, china, Pulsatilla 
and cyclamen. 

The patient may be annoyed also with acidity of the stom- 
ach and heartburn, for which nux vomica, calcarea, natrum 
muriaticum, sulphur, or phosphoric acid is likely to prove effi- 
cacious. We have oftener obtained relief from arsenicum jod. 
than any other remedy. Temporary relief will often be afforded 
by a swallow of pure glycerine, or a half-teaspoonful dose of 
aromatic spirits of ammonia. Flatulent distension may be 
removed by carbo veg., china, lycopodium, nux vomica or 
argent um nit ri cum. 

Neuralgia of the stomach is sometimes very distressing. If 
attended with nausea, ipecac will often relieve; if of a cramp- 
ing nature, nux vomica; if the stomach feels as though dis- 
tended with gas, carbo veg., belladonna, or better still, atropin 
sulph., is often of service. Hot fomentations should be applied 
to the epigastrium. 

The caprices of appetite, so often met, seldom require medica- 
tion, but may serve as valuable indications for the selection of 
remedies in the treatment of other morbid conditions. 

To enable the practitioner to select the indicated remedy 
with greater precision, Ave have adapted from Dr. George W. 
Winterburn's repertory the following: 



Diseases and Accidents. 



221 



GASTRIC AILMENTS. 



Acidity, clc. pul. chin. nux. phos. sul. 

crb. am, chm. ly. kli-c. nit-a. 

stm. nat-m. fer. sul-a. ph-a. tart. 

pet. io. grph. ip. lach. bell. amb. 
Diarrhoea, with, ars. ip. ver. phos. 

lach. bell, tart. col. 
Drinking, after, ars. ver. pul. sil. bry. 

nux. arn. chin. fer. rhs. chm. ac. 
Eating, after, ars. bry. clc. eye. dig. 

lach. mere, nat-m. nux phos. pul. 

sil. sul. ver. crb. ammc. con. fer. 

hyo. ly. sep. nit-a. zn. stm. pet. 

nat-c kli-c. io. grph, chm. an. 

— during, pul. kli-c. mere. ver. fer. 

crb. dig. mag-m. sar. 

relieves, sep. phos. saba. 

Eructations, nat-m. crb. bry. an-t. 

nux. hep. con. arn. sul. thj. stm. 

verb. chin. alu. ver. bell, kli-c. 

mere, mur-a. sep. sta. pet. grph. 

caus. 

— bitter, nux. an-t. sep. chin. pul. 

arn. bell. ver. scil. gra. mere, 
sul-a. thj. bry. 

— burning, io. ph-a. cth. 

— constant, lach. sul. con. 

— empty, sul. con. bry. hep. crb. nux. 

lach. caus. phos. sep. ver. ammc. 
bell. sta. mere, kli-c. nat-c. rhs. 
ru. sab. 

— fetid, sul. 

— food, tasting of, pul. crb. sil. an-t. 

con. phos. ammc. chin. amb. thj. 
nat-m. ly. chel. 

— greasy, crb. 

— ineffectual, phos. caus. con. amb. 

sul. crb. pul. 

— loud, belching, con. pet. 

— nauseous, sep. cin. 

— painful, phos. sep, pet. cocc. saba. 

crb-a. 

— putrid, mere. nux. 

— rancid, thj. 

— relieves, lach. 

— salt, sta. 

— sour, sul-a. nat-m. chm. crb. alu. 

nux. ly. phos. amb. pul. kli-c. 
ph-a. zn. io. asa. chin. 



Eructations accompanied by breathing 
impeded, gra: 

— chest pain. zn. 

— colic, chm. 

— hawking, cup. 

— improvement, lach. 

— nausea, cocc. 

— stomach-ache, phos. 

— throat constricted, nux. caus. 
Eructations occurring, 

— drinking, after, tar. ars. mez. 

— eating, when, nat-c. pet. ol. sar. 
after, nat-m. bry. chin. ars. crb. 

ver. phos. lach. mere. nux. sil. 

clc. thj. sul. 

fat, crb. 

meat, ru. 

— hysteric persons, ru. 

— milk, after, nat-m. sul. chin. zn. 

— morning, early, val. crc. 

— night, lach. sul. 

— smoking, sel. 

Evening, in, pul. phos. eye. an. sil. 
Fat, from, pul. crb-a. sep. drs. eye. 

thj. nit-a. 
Heartburn, clc. sul-a. cap. nat-m. 

am-c. saba. zn. amb. io. ly. crc. 
Heartburn, continually, lob. 

— meals, during, mere. 

— sugar, from, zn. 

Hiccough, ign. ac. str. hyo. nux. pul. 
sul. bov. bell. bry. am-m. mag-m. 
nux-m. sep. coff. clc. ars. cup. 
mur-a. nit-a. ver. grph. mere. 

— painful, teu. 

— spasmodic, nux. str. bell. 

— violent, nux. ly. cic. 
Hiccough occurring, 

— breakfast, after, zn. 

— drinking, after, lach. 

— eating, while, mere. teu. 
after, ver. hyo. eye. mere. 

— evening, in, sil. 

— motion, causes, crb. 

— night, ars. 

Loathing, gra. sen. rat. mag-c. sec. 
lau. asa. 

— beer, after, mur-a. nux. 



222 



Pregnancy. 



Loathing — Continued. 

— meals, after, ip. sars. 

— night, rat. 

Milk, from, clc. sul. 

Morning, early in, dig. sul. sil. nux. 

grph. an. crb. arn. kr. bar. ly. 

phos. chm. lach. 
Mucous disorders, pul. sng. chin. 

mere. sul. cap. bell. ip. ver. rhs. 
Nausea, ip. an-t. nux. tart. sul. 

nat-m. hep. crb. sil. ver. ign. 

grph. an. caus. phos. sta. alu. 

arn. bell. bry. chin. dig. lach. 

mere. ph-a. ru. sep. stm. sul-a. 

sec. nit-a. pet. kli. cup. amb. bar. 

kr. 

— afternoon, in, ran. 

— air, in, ang. bell. 
relieved, ly. 

— breakfast, after, chm. 
before, ip. 

— coffee, after, chm. cap. 

— cold, effects of, cocc. 

— constant, frequent, ip. nux. crb. sil. 

ly. nat-c. kli. ver. scil. mag-m. 
ph-a. 

— drinking, when, nux. 
relieves, phos. 

eating, after, nux. pul. sul. ver. 

sep. rhs. grph. phos. nat-m. eye. 

ars. chm. 
when, kli. ver. pul. fer. crb. 

cocc. 
relieves, sep. kli. phos. 

— eggs, odor of, clch. 

— evening, in, pul. eye. 

— eyes, when closing, ther. 

— fat, causes, pul. crb-a. drs. sep. 
as from, eye. tar. 

— injuries, after, rhs. bry. arn. pul. 

chel. 

— milk, from,, clc. 

— morning, early, ip. nux. sil. an. 

ver. grph. crb. arn. dig. kli. sep. 
phos. 

— motion, ars. pul. kli. crb-a. 

— moise, fright, ther. ign. 

— riding, from, cocc. pet. sul. nux-m. 

sep. sta. 

— spitting, when, led. 



Nausea — Continued. 

— throat, felt in, ph-a. 

— walking, when, kli. 
in air, alu. 

— wine, from, an-t. 
Nausea accompanied by, 

— anguish, kli-c. ign. 

— backache, pul. 

— bitterness in mouth, bell. 

— chilliness, sng. pul. kr. 

— colic, pul. cup. 

— dyspnoea, sng. 

— ears, humming in, ac. 

— eructations, cocc. ac. spig. 

— face, pale, pul. 

gray, mag-m. 

hot, sng. 

red, ver. 

— fainting, arn. bov. ly. 

— hunger, spig. mag-m. 

— loathing of food, with, bell. hell. 

lau. 

— lying down, when, ars. ph-a. 

— thirst, ver. 

— water in mouth, flow of, pet. 
Night, at, ars. rhs. sul. chin. phos. 

nux. 
Regurgitation, food, crb. phos. nux. 
lach. sul. ly. bry. tart. clc. grph. 
pul. sars. sul-a. zn. bell. ign. hep. 
mere. 

— acrid, can. ars. tart. 

— bitter, arn. sars. gra. nux. te 

— bloody, nux. 

— drinks, of, sul. 

— food, of digested, phos. sul. ly. 

chm. bry. ign. lach. con. thj. fer. 
nux. mag-m. cth. 

— green substance, ars. grph. 

— milk, of, ly. tart. 

— rancid, mere. 

— salty, sul-a. 

— slimy, arn. 

— sour, phos. sul. grph. ly. nat-m. 

— sweetish, ac plb. 

— watery, plb. gra. 

— yellow substance, cic. 
Regurgitation occurring, 

— drinking, after, mere. 
milk, clc. crb. ly. 



Diseases and Accidents. 



223 



Regurgitation occurring — Continued. 

— eating, lach. ver. bry. nux. sars. 

asa. fer. 

— night, cth. 

— stooping, when, cic. 

— walking, mag-m. 

Retching, ip. bell. nux. arn. stm. 
mere. plb. bry. asa. tart. op. 
saba. zn. nat-m. 

— bread causes, chin, nit-a. 

Riding, swinging, cocc. pet. fer. bor. 

clch. sil. ly. sul. 
Sour food causes, crb. ac. ars. hep. 

lach. sul. nat-m. 
Sweets, mere. zn. ac. 
Vomiting, ars. ip. pul. nux. ver. chm. 

arn. bry. sec. sep. lach. mere. ly. 

caus. cin. bell. ign. kli. nat-m. 

nux-m. sil. tart. sul. 

— acrid, ip. 

— albuminous, ars. jat. ip. ver. 

— bilious, an-t. nux. chm. pal. ars. 

ac. chin. bry. sep. phos. ip. cin. 
lach. ver. mere. drs. coff. bell. ly. 
sul. col. ign. 

— black, ver. ars. chin. nux. ip. phos. 

clc. pet. sul. plb. 
stains, ar-n. 

— bloody, fer. ac. arn. phos. ip. pul. 

stm. ars. bell. clc. hyo. 

— bluish, cup. 

— brown, ars. bis. 

— drank, what has been, ars. ver. sil. 

hyo. phos. ip. cin. 

— food, of, nux. phos. sul. ars. ip. pul. 

sil. sep. dig. cle. bry. chm. sec. 
fer. grph. hyo. 

— frothy, ver. 

— gelatinous, ip. [ac. pet. 

— green, ars. ver. pul. lach. plb. col. 

— mucus, ars. jat. ip. ver. 

— milk, sam. aet. 

— pitch-like, ip. 

— salt, io. sil. 

— slimy, pul. die. bell. drs. sul. ip. 

ars. mere. an-t. chm. bor. cin. 
ign. gaj. cin. dig. 

— sour, chm. phos. pul. sul. nux. ars. 

bell. chin. fer. tart, sul-a. caus. 
bor. ph-a. 



Vomiting — Continued. 

— sweetish, kr. 

— urinous, op. 

— violent, cup. lach. ver. tart. ars. 

nux. bell. plb. io. mos. 

— ivatery, caus. drs. bry. bell. ip. jat. 

sul. 

— yellowish, ars. kli. 
Vomiting accompanied by 

— agony, ars. 

— anguish, sng. kli. 

— backache, pul. 

— chilliness, pul. 

— convulsions, op. cup. 

— diarrhoea, ars. ver. ip. bell. phos. 

col. lach. 

— drowsiness, tart. 

— eructations, mur-a. nit-a. 
— fainting, clc. 

— foetid breath, ip. 

— face, pale, pul. 

— stomach-ache, ars. cup. nux. phos. 

ver. ip. dig. ac. op. 

— sweat, ip. kli. sul. 
cold, cam. 

— thirst, ip. 

— weakness, ver. ars. ip. 
Vomiting occurring, 

— drinking, after, chin. ver. ars. sil. 

fer. chm. bry, nux. 

— eating, after, ars. phos. nux. sul. 

pul. fer. dig. ac. sep. arn. ver. sil. 
hyo. ac. ip. 
when, pul. rhs. 

— evening, pul. [mos. 

— morning, early, nux. lach. ars. drs. 

— motion, after, ars. bry. nux. ver. 

ther. 

— night, at, pul. ars. fer. phos. nux. 

sul. chin. sil. 

— riding, swinging, cocc. pet. fer. ars. 

clch. 

— improper food, from, pul. ip. an-t. 

nux. bry. sul. 

— stooping, after, ip. 
Waking, lach. 

Waterbrash, clc. sep. crb. pul. sul. nux, 
ars. nit-a. rhs. nat-m. bar. ip. ly. 
bell. pet. 

— acids, after, phos. 



224 



Pregnancy. 



Waterbrash — Continued. 

— alternate days, ly. 

— drinking, after, sep. nit-a. 

— eating, after, sil. sul. 



Waterbrash — Continued. 

— evening, in, eye. 

— morning, sul. 

— night, grph. crb. 



STOMACH. 



Aching, kli-c. ign. con. mere. bell. 

nux. sul. sep. 
Acrid feeling ', hep. 

Alive in, sense of something, ere. sng. 
Anguish, with, chm. nux. crb. spig. 

— from, ars. chm. cup. nux. ver. coff. 

sec. cic. str. 
Animal fluids, chin. crb. nux. 
Anxious feeling, jat. ars. sec. caus. str. 
Atony, of, bell. 
Backache, with, bor. 
Balancing, sense of, ph-a. 
Beaten, as if, euph. asa. 
Bending double, kal. 

relieves, chm. 

Biting in, mos. str. 
Bitterness in, cup. 

— mouth, ly. 

Bloated, ars. kli. nux-m. 

Boring, nat-s. sep. ars. 

Bruised, as if, nux. asa. 

Burning, ars. phos. cic. lach. nux. sep. 

cam. crb. sul. dig. bry. cap. euph. 

zn. sec. cth. mere. lau. nit-a. 

— causing hunger, grph. 

— with vomiting, jat. 
Chagrin, chm. sta. 
Chilliness, with, pul. 
Choking, nux. 

Clawing, sul-a. cocc. crb-a. nux. 
Cold feeling, phos. rhs. chin. cap. ars. 
sp. clch. lau. bar. 

— drinks relieve, phos. 

— from, crb. ly. caus. sul-a. 
Colic, with, cup. col. 

— with spasms in chest, sep. ver. 
Constriction, nux. sul. nit-a. sep. alu. 

plat. phos. 
Corrosion, sense of, iod. nux. 
Cramp, kli-c. an-t. grph. pul. nat-m. 

cic. hyo. caus. stm. 
Crawling in, lact. pul. 
Cutting, cic. nat-c. 



Cutting — Continued. 

— towards spine, sep. 
Debility, clc-p. nat-m. saba. 
Despair, with, an-t. 
Diarrhoea, pul. stm. 
Distension, ly. rat. hell. 

— before eating, crc. 

— sense of. mng. 
Dragging in, sense of, mere. 
Drawing pain, bry. 

Dyspnoea, nux-m. phos. rhs. nux. 
Eat, must, grph. 
Emotions, chm. col. nux. crb. 
Empty feeling, ign. ip. 
Eructations, ars. stm. mag-c. 

— evening, pul. sep. ly. phos. crb. 
Extension, sense of, mng. 
Fermentation, in, crc. 
Flatulence, crb. lach. china. 
Fright, after, crb. 

Full feeling, kli-c, chin. nux. lach. kli. 

nux-m. dap. phos. sul. dig. pet. 

rhe. graph, bar. arn. ly. eye. bov. 

cast. hell. mos. nat-s. 
Fullness, as from undigested food,-ko. 
Gangrene, kli. sec. 
Gastralgia, nux. crb. pul. ac. sul. cocc. 

bell. cic. stm. bis. amme. bry. 

con. ign. ly. sep. nat-c. sil. nux-m. 

mag-c. lach. grph. dap. chin. 

chm. caus. an-t. ar-n. cup. pet. 

— emotions, from, chm. col. nux. 

— hysteric persons, ign. gra. mag-c. 

— loss of fluids, caused, chin. nux. crb. 

— portal congestion, nux. crb. 

— salt, from, crb. 

Griping, sil. phos. nux. pul. nat-m. 

sul-a. caus. cic. 
Groaning, moaning, with, nux. ars. 
Gurgling, flu. kli-i. an. lob. verb. mens. 

— when drinking, thj. cin. lau. cup. 
Heat, sense of, ars. sep. chin. 

— head, with, caus. 



Diseases and Accidents. 



225 



Hunger, stm. 

Hysteric persons, ign. cocc. nux. 

mag-c. 
Jumping, sensation of, crc. 
Morning, early, nat-m. an. sta. nux. 
Nausea, dig. ars. nux. crb. stm. nat-m. 

sul. ip. mere. 
Night, at, phos. grph. nux. crb. sul. 

chm. ar-n. 
Numb fingers, with, ly. 
Numbness, sense of, cast. 
Pain in chest, with, arn. sul. 

— stomach, clc. nux. arn. bry. ver. 

spig. 
Palpitations, with, nux. lye. 
Periodical pain, ly. ign. hyo. 
Pressed upon, when, ly. bry. sil. nux. 

nat-m. pul. 
Pressing foot on ground, when, bry. 
Pressure, ly. nux. rhs. sep.bis. nat-m. 

chm. sil. pul. phos. grph. crb. 

bell. hep. ign. gra. cic. mere. 

plat. ars. bar. clc. caus. die. ip. 

lach. fer. nat-c. plb. sta. rho. 

— stone, as from, nux. ign. chm. lach. 

mere. sep. spig. 
Pulsation, see Throbbing. 



Relaxed feeling, ip. 

Restlessness, cth. [caus. 

Rolling, rumbling, phos. crc. verb. hell. 
Sensitiveness to contact, sul. nux. bry. 
clc. ly. lach. hep. 

— to pressure of clothing, ly.bry. nux. 

clc. sul. hep. spig. 
Sore, pain as if, nux. bry. lach. 
Spasms, ang. 
Stitching in, sep. rhs. nit-a. bry. clc. 

kli-c. 
Stricture, as if, nux. phos. 
Swallowing, when, bar. 
Swelling, sense of, bry. 
Throbbing, ol. pul. nux. asa. sep. 
Touched, when, phos. sul. bar. nux. ars. 

bry. clc. nat-c. spig. mere. cup. 
Twisting sensation, nat-m. 
Ulcerative pain, crb. nat-m. rhs. 
Violent pains, ars. ver. cup. phos. hell. 

lach. plb. ip. 
Vomiting, ip. ars. ver. nux. cup. phos. 

op. bry. pul. dig. 

— relieves, hyo. 

Walking, while or after, sep. clc. phos. 
Water, as if full of, mil. phe. 
Weakness, sense of, ign. dig. 



Ptyalism, or excessive flow of saliva, is frequently associated 
with pregnancy. In a few cases, the secretion has amounted to 
two or three quarts in the course of the day. The remedies 
best calculated to relieve are those which follow: 

Belladonna. — Much mucus in the mouth; great flow of 
saliva ; violent constriction of the fauces ; violent constrictive 
pain at the scrobiculum; long-lasting gastralgia; continual 
pressure to urinate ; passage of scanty urine ; frequent passage 
of pale, watery urine; violent pressure and bearing down 
towards the sexual organs ; pressure in the cardiac region. 

Cocculus. — Running of saliva from the mouth ; choking con- 
striction in the throat; gastralgia; watery urine is passed in 
large quantities at short intervals. 

Conium. — Salivation; faucial and gastric spasms; constric- 
tive pain in the stomach with sensation of coldness in the stom- 
ach and in the back; very frequent urging to urinate and 
scanty passage; crampy pains in the lower portion of the.- 
abdomen. 
(15) 



226 Pregnancy. 

Natrum mur. — Constant collection of water in the mouth, 
compelling her to spit frequently; constrictive gastralgia 
with sensation of coldness in the stomach and back; 
pressure in the abdomen every morning; pain as from a load 
in the abdomen, or as though everything would be torn apart 
while walking ; pressure and bearing down from the side of the 
abdomen towards the sexual organs, in the morning, compel- 
ling her to rest quietly ; frequent passage of profuse, hot urine, 
with violent urging, as often as every half-hour, even while 
drinking less than usual ; pressive pain in the cardiac region in 
the morning. 

Nux vom. — Frequent collection of saliva in the mouth; 
asthmatic, constrictive oppression across the chest while walk- 
ing and ascending; cardialgia and convulsions; constrictive, 
oppressive pain in the stomach ; continuous pain in the stom- 
ach ; frequent ineffectual urging to stool, even after a sufficient 
evacuation; bearing down in the abdomen towards the sexual 
organs; painful, ineffectual urging to urinate; increased quan- 
tity of urine, exceeding in amount the quantity that was 
drunk; pain in the abdomen and bearing down towards the 
sexual organs while walking in the open air. 

Secale. — Increased secretion of saliva ; severe pressure in the 
stomach without loss of appetite; gastraigia; urination is 
accomplished with difficulty, with frequent urging thereto; in- 
creased passage of watery urine. 

Veratrum. — Salivation; much tasteless water runs into the 
mouth; crampy constriction in the pharynx, and gagging; 
cardialgia ; violent pressure in the scrobiculum ; pressure in the 
cardiac region ; pressive pain in the bladder ; palpitation of the 
heart. 

Kalijod. — l x has proved efficacious in many obstinate cases. 

Other remedies Sbrejaborandi, mercurius, and acetic acid. 

Pruritus. — Distressing itching, without visible affection of 
the skin, occasionally torments pregnant women beyond all 
endurance. The affection may be limited to the distended 
abdominal walls, and, in other cases, to the vulva and vagina. 
It is most frequently a reflex nervous affection; at other times 
the result of irritating vaginal discharges; and again the effect 
of ascarides. When the vulva and vagina are the parts in- 
volved, the vagina should receive a douche, made up of water 
in which has been put carbolic acid, borax or hydrastis, and 
the vulva washed with the same. What some regard as a still 



Diseases and Accidents. 227 

better wash is aqua menthae piperita?. If dependent on ascari- 
des, a wash composed of an infusion of tobacco or garlic may 
be used. 

A mild galvanic current, with the anode at the vulva and 
the cathode on the sacrum, will sometimes relieve. When the 
abdominal surface is the seat of the trouble, temporary relief 
may be obtained from the local use of chloroform liniment or a 
solution of carbolic acid. The principal homeopathic remedies 
are borax (which should be used both locally and internally), 
conium, platina, sepia, graphites, petroleum, tarantula, and 
collinsonia. 

It may be that the distressing itching is chiefly in the ure- 
thra, in which case injection of a two per cent, solution of 
cocaine affords immediate relief. It will require a few, but not 
frequent, repetitions. We have been driven to the use of this 
remedy upon the vulva and within the vagina, in a few in- 
stances. 

Face-ache.— Neuralgia of the fifth nerve is often experienced, 
and atropin, belladonna, arsenicum or gelsemium will gener- 
ally relieve it. Should the indicated remedies fail to afford 
relief, resort may be had to the external application of aconite, 
chloroform or camphor liniment. The continued use of hot 
water is sometimes a great aid; and the galvanic current is 
often efficacious. 

Cephalalgia.— The remedy may be selected according to the 
following symptoms : 

Bryonia. — Bursting or splitting headache ; dryness of mouth 
and lips. 

Natrum mur. — Awakens every morning with a violent head- 
ache. 

Actsea rac. — Pain over either eye, or in the eyeballs. 

Belladonna. — Sense of great fullness of the head. 

Nux vomica, gelsemium, aconite, glonoinum — Head feels much 
too large. 

Belladonna, bryonia, calc. carb. — Fullness and heaviness of 
the forehead. 

Belladonna. — Determination of blood to the head, with throb- 
bing headache ; right-sided headache. 

Argent, nit.— Sensation of great expansion, especially of the 
head and face. 

Mercurius— Pressing headache from both sides as if the 
head were in a vise. 



228 Pregnancy. 

Phos. acid.— Dreadful pain in the vertex as if the brain were 
crushed. 

Aconite.— Piercing throbbing pain in forehead, worse from 
motion; brain feels as though it would press out at fore- 
head. 

Kali bich.—Fam of a dull, heavy, throbbing character, mainly 
in the forehead, worse after eating. 

Lachesis. — Beating headache, most violent over the eyes. 

China. — Throbbing headache after excessive depletion. 

Glonoinum. — Throbbing in the temporal arteries. 

Nux moschata. — Headache from eating too much. 

Calcarea carb. — Beating headache, seemingly in the middle 
of the brain. 

Sepia. — Beating headache in the occiput. 

In every case of severe headache in pregnancy the urine 
ought to be tested for albumen, and to determine the quantity 
of urea, for fear that an impairment of the renal function lies 
back of the symptom. 

Insomnia— Continued sleeplessness is not only distressing 
to the patient, but it is liable so to reduce her vital energies as 
to render her poorly prepared to undergo the violent strain of 
labor. Moderate exercise, pure air and frequent baths, will 
generally bring the needed repose. Certain remedies will aid : 

Act sea rac, hyoscyamus, coffea, caulophyllum. — Sleepless- 
ness. 

Aconite, arsenicuw alb.— Sleeplessness and restlessness. 

Sulphur. — Drowsy during the day ; sleepless at night. 

Nux vom. — Cannot sleep after 3 a.m., ideas so crowd upon 
the mind. 

Calcarea carb.— Cannot sleep after 3 a.m. 

Calcarea carb., china. — Cannot sleep because of involuntary 
thoughts. 

Belladonna. — Sleepy but cannot sleep. 

The last remedy, in our experience, is indicated oftener than 
any Other. 

Anaemia. — In our account of the changes wrought in the 
organism by pregnancy, we entered somewhat in detail into an 
account of the blood-changes which take place, and to that we 
now refer for the pathology. As the result of these changes, 
symptoms of a more or less aggravated nature develop, vary- 
ing in degree to correspond with the extent of deviation from 
the normal type. Within limits, the changes may be regarded 



Diseases and Accidents. 229 

as normal, but when they become excessive, the organism shows 
signs of suffering and deterioration. The red blood corpuscles 
being reduced in number, if the diminution continue, the cell 
elements suffer, and finally waste, or fill with fatty molecules. 
Then follow loss of weight, muscular prostration, impaired 
functional activity of the secretory organs, and increased nerve 
irritability. All the functions of the body are impaired, and 
the patient, unless the morbid changes become arrested, soon 
sinks to death. While such a termination is not impossible, 
the deterioration and disintegration are usually brought under 
control, and the patient is ultimately restored to a fair degree 
of health. 

This distressing condition is much more easily prevented 
than cured. Preventive treatment lies in the direction of obedi- 
ence to the laws of hygiene governing both mind and body. 
" Light, air, moderate exercise, good food, regulation of the 
bowels, cheerful society, and an occasional respite from house- 
hold and family cares, will always be the main checks to its 
extreme development." 

As a result of hydrsemia, there may be extensive oedema, 
which gives rise to much discomfort, and requires special atten- 
tion. When it is extreme in certain parts, gangrene may 
threaten, and puncture be required. If the skin of the lower 
limbs becomes painful from great tension, application of hot 
cloths will afford some relief. 

Medicinal treatment consists in the administration of one or 
more of the following remedies, the action of which should be 
prolonged, since beneficial effects are slowly manifested, 

Ferrum, in one of its several forms, is most frequently em- 
ployed with good results. The metallicum is often used, as w r ell 
as ferrum et strychnia, citrate, and ferrum phosphoricum. 

Pulsatilla is capable of affording relief in some of these cases, 
especially when the attack is of the milder type. There is con- 
stant chilliness, coldness, and paleness of the skin ; coldness of 
the feet; irregular pulse, and palpitation of the heart; want of 
appetite; vertigo, especially on rising; mild, w r eeping mood, or 
excessive irritability. 

None of the foregoing remedies have been in our hands as 
serviceable as arsenicum jod. The arsenicum album may do 
as well in most instances. When these remedies are indicated, 
there are pallor, more or less oedema, restlessness and a sense 
of weakness. 



230 Pregnancy. 

Nux vomica, when indigestion is a troublesome feature, and 
there is constipation, or small loose stools, with urging. 

Numerous other remedies will be found useful, such as 
helonias, phosphorus, cyclamen, calcarea carb., sulphur, etc. 

For the dropsical symptoms, we find help in arsenicum 
album, apis met, helleborus and apocynum can. When lim- 
ited to the feet and legs, bryonia may be the remedy. 

Albuminuria. — Albuminuria, associated with pregnancy, 
was little known by the profession until within about forty 
years. Koger, in France, and Lever, in Great Britain, were the 
first to direct attention to its intimate relationship to that ap- 
palling complication of pregnancy and puerperality, eclampsia. 
For many years it was supposed that convulsions occurring in 
the pregnant or puerperal woman were always preceded by, and 
in a measure dependent on, albuminuria. But more recently it 
has been shown that this is not true, for in some cases albumin 
is not present in the urine until after convulsions have begun ; 
and again it does not appear at all. 

Albuminuria is also associated with other affections to which 
pregnant women are subject, as for example, puerperal mania, 
vertigo, headache, and certain forms of paralysis, either of the 
nerves of special sense, as in the instance of amaurosis, or of 
the spinal system. The relation which it bears to these diseases 
is not yet well understood. It should always be regarded with 
apprehension, and vigorous efforts made for its removal. 

Blot and Litzman met it in twenty per cent, of all cases ex- 
amined, but this is far above the estimate of other authors. 
Dr. Fordyce Barker believes it occurs in about one out of 
twenty -five cases, or four per cent., and Hofmeir found it in 137 
out of 5,000 women delivered in the Berlin clinic, which represent 
about 2.74 per cent. In most cases it disappears soon after 
delivery, and hence the causes upon which it depends must be 
temporary. It follows, therefore, that albumin in the urine of 
pregnant women, while it justly arouses considerable anxiety, 
does not always assume the grave importance which it does in 
the n on -pregnant state. 

Causes.— The origin of this disorder is usually sought in the 
conditions of pregnancy, but beyond this point opinions greatly 
diverge. The blood-changes already described as taking place 
in pregnancy, may have a causative relationship to albumi- 
nuria. Still, it is observed that in the worst cases of anaemia 
during gestation, albumen is rarely found. 



Diseases and Accidents. 231 

It is supposed by some that albumin in the urine is due to 
congestion of the renal vessels by the gravid uterus. This may 
be true of some cases, but, in general, it cannot be regarded as 
the only, or even the chief, cause, as a similar pressure is ex- 
erted by uterine and ovarian tumors without producing such 
an effect. 

The increased arterial tension doubtless constitutes an im- 
portant causative factor. All careful observers have found it 
much above the normal. Fancourt Barnes believes it possible 
to predict " with almost absolute certainty, albuminuria, with 
its usual puerperal complication, eclampsia," from the in- 
creased and increasing vascular tension. 

In a certain number of instances, albuminuria antedates 
pregnancy. When this is true, there is during gestation nearly 
always an aggravation of the pathological condition. 

Symptoms. — One of the most common symptoms of al- 
buminuria is oedema, which is a dropsical condition of the 
subcutaneous cellular tissues. It is exhibited especially in 
the extremities and face, and sometimes becomes excessive. 
(Edematous swelling of the feet and legs is observed in a large 
proportion of pregnant women, though it is associated with 
albuminuria in only a small proportion of them. Sometimes 
the oedema spreads until it becomes general anasarca, and the 
woman presents a pitiable aspect. 

There are also many nervous symptoms connected with 
albuminuria, such as vertigo, cephalalgia, dimness of vision, 
spots before the eyes, and nausea. The appearance of such 
symptoms in a pregnant woman, whether associated with 
oedema, or not, should impel the physician to a thorough chem- 
ical and microscopical examination of the urine. 

The Effects. — The various diseases associated with albu- 
men in the urine, either as cause or effect, require separate con- 
sideration, inasmuch as some of them are among the most 
dangerous complications to which a pregnant woman is liable. 
Several of these have been alluded to as symptoms of albu- 
minuria, such as cephalalgia, vertigo and paralysis ; but that 
which stands out most prominently is eclampsia. The precise 
mode in which the last named disease is produced will be con- 
sidered when we come to discuss in detail the cause, course and 
treatment of it in another chapter. The acutest cases are 
most hopeful. Those in which albuminuria sets in early are 
extremely liable to become chronic. 



232 Pregnancy. 

We have before said that albumin appears in the urine 
of women suffering from puerperal mania, and various forms of 
paralysis ; but whether as cause or effect, cannot be positively 
stated. 

Prognosis.— The danger to mother and child in connection 
with albuminuria in pregnancy is not slight. Goubeyre esti- 
mated that forty-nine per cent, of primiparse who manifest the 
diseased condition, and who escape eclampsia, die from morbid 
results traceable to the albuminuria. Hofmeir found that out 
of forty-six cases reported by him, only one-third had eclamp- 
sia, though one-half died. Including both acute and chronic 
cases, Braun estimates that only sixty in the hundred develop 
ursemic convulsions. Hofmeir found in five thousand births 
recorded upon the books of the Berlin Clinic, 137 cases of 
nephritis entered. Out of this number only 104 patients were 
attacked with eclampsia. Prof. Bamberger reports from 
autopsies of the "allgemeinen Krankenhaus, v in twelve years, 
2,430 cases of Bright's disease, of which 152 were found in 
puerperal and pregnant women, namely: 80 acute cases, 56 
chronic cases, and 16 cases of atrophy. Puerperal eclampsia 
was recorded in 23 of them. 

A modifying condition has been shown by Bailly to exist, 
namely, that not rarely albuminuria in pregnant women dis- 
appears for several hours, and then reappears, so that it may 
happen that an examination is made during the short period 
when the urine ceases to be albuminous. It should be borne in 
mind, however, that it is the renal insufficiency, and not the 
albuminuria, which causes uraemia and convulsions. The mere 
absence of albumin from the urine does not even exclude the 
existence of Bright's disease. 

Convulsions occur more commonly in primiparae than in 
multipara?, especially in elderly primiparae, in twin pregnancies, 
in women with contracted pelves, and in connection with the 
delivery of male children. They may occur epidemically in 
consequence of atmospheric conditions, which probably inter- 
fere with the functions of the skin, modify the peripheral 
circulation, and thus indirectly increase the labor thrown on 
the kidneys. 

The danger of eclampsia is decided and unmistakable; but 
besides this, owing to imperfect nutrition of the foetus, by ma- 
ternal blood impoverished through loss of albumin, there 
is manifested a strong tendency to abortion. This fact has 



Diseases and Accidents. 233 

been observed by many authors. A good illustration of it is 
given by Tanner, who states that out of seven women he at- 
tended, suffering from Bright's disease during pregnancy, four 
aborted, one of them three times in succession. 

The urine usually presents the common indications of serious 
renal involvement, namely, scantiness, high color, epithelial 
cells, tube-casts and occasionally blood. 

Conclusions. — Leopold Meyer, from observations upon 
1,124 pregnant and 1,138 parturient women, draws the follow- 
ing conclusions : 

1. Tn 1,124 non-selected cases of pregnancy, he found albu- 
minuria in sixty-one cases (5.4 per cent.), in twenty-two of 
which he also found casts 2 per cent.) 

2. Albuminuria with casts occurred a little oftener in those 
cases where albuminuria appeared for the first time in the 
earlier months of pregnancy than in those where it appeared 
later on. 

3. The age of the women had no influence in regard to the 
frequency of albuminuria. 

4. Albuminuria with and without casts occurred most fre- 
quently between the 101st and 170th days and between the 
first and fourteenth day before parturition. 

5. Of those women who had not albuminuria 19.7 per cent, 
had premature labors ; of those with albuminuria but without 
casts 27.7 per cent. ; of those with albuminuria but with casts 
41.2 per cent. 

6. Of pregnant women who had albuminuria without casts 
55 per cent. w r ere free from it, and healthy during labor; of 
those who had albuminuria with casts only 12 per cent, had no 
albuminuria when at full term. 

7. Of 1,138 parturient women, 25 per cent, had albuminuria 
without and 12 per cent, with casts. 

8. Albuminuria during parturition wasalittle more frequent 
in the primiparse than in the multipara?. 

10. Albuminuria without casts, which was only observed 
during labor, and did not exist before, disappeared as a rule 
rapidly. 

11. Albuminuria with casts, disappeared as a rule rapidly 
after parturition, generally after the 4th day. Yet occasionally 
it persisted longer, especially if it had existed during preg- 
nancy. The age nor the number of pregnancies had any influ- 
ence on the course of the disease. 



234 Pregnancy. 

12. Of the women who had not albuminuria 1.9 per cent, 
had still-born children. Of those with albuminuria but with- 
out casts, 2.1 per cent, of those with albuminuria and casts, 
2.9 per cent. 

Treatment. — It is extremely desirable to recognize this dis- 
ease in its incipiency, and in order so to do, every case which 
presents suspicious symptoms ought to be carefully examined. 
It is a lamentable fact that, in the larger number of instances 
in general practice, the medical adviser has no knowledge of 
the woman's condition until convulsions set in. 

Treatment should be modified to meet the various indications 
presented by individual cases. The stage of the reproductive 
process at which the woman has arrived, namely, pregnancy, 
labor or puerperality, the severity of the symptoms, and the 
cause of them, are all important considerations. If the cause 
of the albuminuria is traceable to pressure of the gravid uterus 
on the surrounding organs, thereby producing hyperemia of 
the renal secretory apparatus, treatment ought to be varied in 
some essentials from that which would be employed when albu- 
men in the urine is referable to a different cause. Again, a 
slight trace of albumen, with no pending constitutional dis- 
turbances, would not justify the same heroic treatment which 
might seem indicated when convulsions threaten the patient's 
life. 

Frequent examinations of the urine ought to be made with 
special reference to ascertaining the quantity of albumen and 
urea. A woman weighing 140 pounds ought to excrete 500 
grains of urea every twenty-four hours ; and when the quantity 
falls much short of that in a given case, uremic symptoms are 
liable to develop. 

The prominent indications for us to follow are, to diminish 
the tendency to renal congestion, and to bring the blood into 
its normal condition. 

The Milk Diet. — The regulation of diet is one of the most 
essential features of treatment. All obstetricians agree in 
recommending milk as the exclusive article of food. Tarnier 
gives the following rules for guidance, to be adopted as soon as 
the albumen appears in any considerable quantity in the urine: 

First day, a quart of milk, with two portions of food. 

Second day, two quarts of milk, with one portion of food. 

Third day, three quarts of milk, with one-half portion of 
food. 



Diseases and Accidents. 235 

Fourth and following days, four quarts of milk, or miik ad 
libitum, without other food or drink. 

In severe cases, if prodromata of eclampsia appear, put the 
patient at once on three or four quarts of milk per day. The 
influence of the milk diet is never slow in manifesting itself, and 
in eight to fifteen days after beginning this treatment, the al- 
buminuria is diminished very considerably, or even cured. 

This diet will not be equally well borne in all cases; but by 
judicious management, and the use of indicated remedies, it 
will nearly always become tolerable. 

Therapeutics. — Homeopathy has provided us with remedies 
which have a most salutary effect on this disease. Among them 
mercurius corrosivus occupies the highest place. " Experience," 
says Dr. Ludlam, "has led me to place great confidence in the 
mercurius corrosivus. I have prescribed it very frequently to 
fulfill this precise indication, and it has seldom disappointed 
me. * * * The idea which I design to convey is not that 
this, or any other remedy, is an absolute specific for ante- 
partum convulsibility. There is no real prophylactic of puer- 
peral eclampsia. But if in one case in ten you can recognize 
incipient symptoms of this dreadful disease, and avert it, you 
should know how to do it/' 

Arsenicum is a valuable remedy. The oedema is observable 
iu the face, especially about the eyes; the countenance is pale; 
the thirst intense ; the patient restless ; the urine scanty and 
passed with difficulty. 

Apis. — Urine scanty and high colored, albuminous, and con- 
taining uriniferous tubules and epithelium; oedema of face, 
hands and lower extremities; cedematous eyelids; great pros- 
tration in association with pale waxy skin ; drowsiness with 
restlessness ; irritation of bladder ; frequent desire to urinate, 
with the passage of only a few drops ; no thirst ; patient tear- 
ful and absentminded. 

Glonoinum. — Abundant, highly albuminous urine, which she 
must rise at midnight to pass; urine high-colored, and burn- 
ing. In connection with these indications of renal fullness, we 
have, as corroborative symptoms, the violent headaches pecu- 
liar to this drug, congestion of the head with paleness of the 
face, throbbing felt with every pulsation of the heart, at every 
step or jar; blood mounts from neck, throat and chest,— 
from occiput to eyes ; pressure from within outwards in both 
temples; brain feels too large and as if it would burst, impelling 



236 Pregnancy. 

her to hold both hands to the sinciput ; laborious action of the 
heart ; the patient in bad humor. 

Helonias. — Albuminuria during pregnancy. Urine profuse, 
clear, and light-colored ; frequent desire ; urine burns ; heat and 
pain in the region of the kidneys, so that their outlines can 
thereby be traced ; aching and tenderness of the kidney, weari- 
ness, languor and weight in the region of the kidneys ; general 
malaise, unusually tired; drowsy, sleepy, melancholy mood. 

Cantharis. — Not often indicated in the ordinary albuminuria 
of pregnancy ; but may be the only remedy when acute neph- 
ritis occurs, or when an acute attack is engrafted upon a neph- 
ritis already existing. Urine turbid, scanty and containing 
mucus, casts and shreds. Pains in the loins and abdomen, with 
pain on urinating, and with constant desire. Convulsions, with 
oedema. 

Antimonium tartaricum. — Patient in bad humor; urine 
brownish-red, scanty, turbid and of strong odor. Blood con- 
tains urine. Associated with these conditions of the urine, the 
gastric derangements peculiar to the remedy are sometimes 
observed, such as vomiting of mucus, belching, disgust for food, 
and salivation. There may also be bronchial catarrh, dyspnoea, 
and pulmonary oedema consequent on uremic oppression of the 
nerve centers. The face is pale, and the tongue is white. 

Argentum nitricum. — Urine sufficient in quantity, but it 
contains a relatively large quantity of albumen. 

ColchJcum. — Pain in renal region, frequent urination, but 
diminished excretion; weakened memory, clouded intellect, 
mental depression, occipital pressure. This remedy frequently 
does excellent service. 

Helleborus — Frequent desire, with scanty urine. 

Phosphorus. — Albumen, and exudation cells in the urine. 

Terebinthina. — Urine scanty, dark and albuminous. 

Kalmia is often useful, though in the recorded provings 
there are no indications of its value in kidney affections. By 
virtue of its power over the heart, and secondarily over the 
kidneys, its use has been followed by good results, especially 
when great and persistent aching pains in the limbs were present, 
without evidence of local inflammation. 

Induced Labor for* Albuminuria. — Allusion is sometimes 
made to this as "Schroeder's method." In obstinate cases the 
question of resort to this operation is forced upon us. Hofmeir 
believes that it does not increase the risk of eclampsia, while it 



Diseases and Accidents. 237 

may altogether avert an attack. The operation has been ad- 
vocated by others. On the other hand, Spiegelberg opposes it, 
and Fordyce Barker thinks it should be resorted to only "when 
treatment has been thoroughly and perse veringly tried with out 
success for the removal of symptoms of so grave a character 
that their continuance would result in the death of the patient. " 
"We discard," says Charpentier, "the question of premature 
labor for the following reasons : 

"1. The success which we have had with the milk diet is such 
that we believe all other treatment useless, particularly when 
the milk diet is carefully and sufficiently observed during preg- 
nancy, and soon enough to produce its effects. 

"2. When the albuminuria is slight, the interruption of 
pregnancy appears useless, the gravity of the accidents which 
occur in pregnant women, who are at the same time albumi- 
nuric, being, in general, in direct relation with the amount of 
albumen. 

"3. When albuminuria, produces serious symptoms, it de- 
pends upon, not only pregnancy, but also a serious renal 
affection, which may progress after confinement, and cause, as 
the observations of Hofmeier prove, the death of the patient. 

"4. Labor, as we have seen, has a marked influence in the 
production of albuminuria and of eclampsia; and, as the in- 
duction of premature labor, and with still more reason, abor- 
tion, always requires a certain length of time, the result may 
be that, during this time, the patient may be placed in a condi- 
tion still more unfavorable than that in which she already is, 
by the mere fact of the albuminuria from which she is suffering. 

"Finally, although it is true that, in a number of cases, al- 
buminuria has disappeared after the death of the foetus, and 
the real cessation of pregnancy, there are many other instances 
in which it has reappeared at the onset of labor, accompanied 
or not by eclampsia." 

"It is not easy," says Playfair, "to lay down any definite 
rules to guide our decision ; but I should not hesitate to adopt 
this resource in all cases in which the quantity of albumen is 
considerable, and progressively increasing, and in which treat- 
ment has failed to lessen the amount; and, above all, in every 
case attended with threatening symptoms, such as severe 
headache, dizziness, or loss of sight. The risks of the opera- 
tion are infinitesimal compared to those which the patient 
would run in the event of puerperal convulsions supervening, 



238 Pregnancy. 

or chronic Bright's disease becoming established. As the opera- 
tion is seldom likely to be indicated until the child has reached 
a viable age, and as the albuminuria places the child's life in 
danger, we are quite justified in considering the mother's safety 
alone in determining on its performance." 

We believe few cases, if properly managed, will prove intrac- 
table to the milk diet and suitable remedies, but in those which 
do, we should not hesitate to bring on premature labor, and 
hasten it to a close. 

Chorea During Pregnancy. — Chorea gravidarum. — This, 
fortunately, is a rare complication, and occurs chiefly in young, 
nervous women, a large percentage of whom have had chorea 
in childhood. It most frequently sets in during the third, 
fourth or fifth month. Among the recognized causes, apart 
from heredity, are anaemia, profound emotions and repercussed 
eruptions. The mere irritation arising from normal develop- 
ment of the ovum in certain susceptible women, may constitute 
an efficient cause. 

Its prognosis, in cases brought under suitable treatment, 
does not appear to be as grave as some authors would lead us 
to believe. Still it must be regarded as a serious affection. Dr. 
Barnes compiled fifty-six cases, of which number seventeen 
died. Its danger is not to life alone, for it appears that the 
disease is quite liable to leave permanent impairment of the 
mental faculties. It has also an unquestionable tendency to 
excite abortion and premature labor, and hence to sacrifice 
foetal life. 

Treatment. — Special effort should be made to protect the 
patient from all possible sources of irritation, and to render her 
surroundings as pleasant as possible. Good food, fresh air, 
regular baths, followed by brisk rubbing, and such exercise as 
she can bear without great fatigue, are the general indications 
for treatment. "There are nervous conditions which simulate 
chorea," writes Dr. Ludlam, " that yield readily to such remedies 
as belladonna, ignatia, coffea, nux vomica, agaricus, and cuprum, 
under appropriate indications. These states are temporary, 
and often depend upon avoidable causes. They are easily cured." 

Spasms of chorea caused by fright, require aconite, ignatia, 
opium or cuprum. 

When proceeding from suppressed eruptions, cuprum aceti- 
cum, sulphur, calcarea carb., arsenicum and causticum are the 
remedies from which selection should be made. 



Diseases and Accidents. 239 

When the cause remains latent the remedies from which to 
choose are veratrum viride, belladonna, Pulsatilla, sepia, 
sabina, gelsemium, tarantula and caulophyllum, the particular 
indications for which will be found mainly in the mental and 
physical traits, taken in connection with collateral manifesta- 
tions. 

If, in spite of our remedies, the paroxysms increase in severi- 
ty, and the patient's strength appears to be exhausted, counsel 
agreeing, labor may be induced. The choreic manifestations 
usually terminate with complete evacuation of the uterus. 

The propensity of chorea to recur in successive pregnancies 
should be remembered, and precautions of the best character 
adopted. 

Hysteria.— Well-marked hysteria is not commonly observed 
in pregnancy, though many women evince symptoms of a ner- 
vous character, which, in some respects, resemble it : hence we 
find that authors have little to say about it. Such symptoms 
are more prone to appear in the early part of gestation, and 
may condense into distressing convulsions. Indigestion, exces- 
sive fatigue, loss of sleep, and a variety of occurrences and con- 
ditions, operating on a nervous system very sensitive, and 
already a little out of tune, may so confuse its action as to set 
the various functions to work at cross purposes. 

Mere remedies, however well suited to the case, are hardly 
sufficient. The disorder being largely emotional, the patient's 
mind has to be brought under subjection, not by harsh, but by 
the gentlest possible, measures. Anything which is calculated 
to strike the fancy, to divert, overwhelm or control the emo- 
tional elements of her nature, if not brought to bear with too 
much force and energy, will have a beneficial effect. These cases 
are exceedingly difficult to handle, and demand the exercise of 
our best judgment and keenest tact. The judicious employment 
of friction, electricity, bathing and exercise, is to be recom- 
mended. Even hypnotism may be cautiously employed. Elec- 
tricity ought to be used with great caution, for fear of exciting 
uterine action. 

Among the remedies most frequently employed are the 
following: 

lgnatia. — This remedy most happily affects women of a 
nervous temperament, of dark hair and eyes, of quick mental 
faculties, and with an inclination to low spirits. They are 
exceedingly sensitive to the discomforts and inconveniences of 



240 Pregnancy. 

their state, and may quietly grieve, or become greatly vexed 
over them. 

Pulsatilla.— The temperament here is not necessarily ner- 
vous, but there are the delicate sensibilities, light complexion, 
fair skin, and mild eyes, — most frequently blue. The weeping 
mood is characteristic. The temper is sometimes petulant, but 
the tears are quite likely to soften its effect. 

Caulophyllum.—We have found this a very useful remedy, 
but its characteristics are not clearly defined. 

Nux moschata.—The woman, instead of being excessively 
sensitive to impressions, is quite the opposite. She is inclined 
to stay within doors, and takes but little interest in what is 
going on about her. The mental faculties are dull, the memory 
weak, and drowsiness is well marked. 

Nux vomica. — This remedy acts chiefly on the spinal cord, 
and the effect is excitement. The mental traits are character- 
istic, there being irritability, dislike for work and disgust for 
life. The temperament is masculine, but nervous. We have 
not often found this an indicated remedy. 

Moschus. — Women of excitable disposition, melancholy 
mood, with a tendency to coldness. It is especially valuable 
for its immediate effects upon hysterical paroxysms. 

Gelsemium. — Sometimes of service when there are depression 
of spirits, restless sleep, aching in the limbs, weakness and 
trembling. 

Many other useful remedies might be mentioned, but those 
named have in our hands proved most beneficial. 

Paralysis. — Pregnant women seem peculiarly liable to vari- 
ous forms of paralysis, but more especially hemiplegia and 
paraplegia, the former being more frequent. The subject is too 
extensive for anything more than brief mention here. In a 
general way it may be said that the disease seems in many 
cases to be associated with albuminuria and uraemia. 

Many modern authorities advise the induction of premature 
labor in cases wherein paralysis appears in connection with al- 
buminuria; but the results of the milk diet and homeopathic 
medication are so satisfactory that the advice should be re- 
ceived with caution. Upon disappearance of the albuminuria 
the paralysis usually improves. If it persist, the induced cur- 
rent, friction, bathing, and a continued use of the homeo- 
pathic remedy, usually prove effectual. For the relief of 
paralysis not associated with, or dependent upon, albumi- 



Diseases and Accidents. 241 

nuria, the induction of premature labor would be manifestly 
improper. 

The results of homeopathic medication, when aided by the 
milk diet, are in the main so satisfactory that the cases of pa- 
ralysis dependent on albuminuria, calling for the induction of 
premature labor, are few. The remedies of greatest service 
have already been given under the head of " albuminuria," and 
need not be repeated here. If we are driven to the induction of 
labor, or if it comes on naturally, without relief of the para- 
lytic condition, the remedies which will be most beneficial are 
nux vomica, gelsemium, mercurius cor., arsenicum, sulphur and 
calcarea carb. 

Syncope.— Attacks of syncope, while not very common, are 
experienced by pregnant women. They oftener occur during 
the first three trying months, w r hen all the functions are more 
or less disturbed, and the nervous system so very sensitive to 
every impression. The attack is not often a fully-developed 
fainting fit, and hence consciousness is not entirely lost ; yet 
the patient may lie with dilated pupils, feeble pulse, and in semi- 
consciousness, for several minutes, or much longer. 

In the way of treatment, lay the patient on her back, with 
the head low; supply plenty of fresh air. and give ammonia, 
amyl nitrite, or spirits of camphor, by inhalation. If the at- 
tack be prolonged, a sinapism to the precordia will be found of 
good effect. Select a remedy according to the symptoms : 

Aconite, cact. grand.— Palpitation of the heart. 

Arsenicum. — Debility or prostration. 

Bryonia. — Great thirst and drinks much cold water. 

Camphor. — Very weak pulse; coldness of the whole body. 

Carbo veg. — Eructations. 

Chamomilla. — Irritability; dimness of vision; nausea. 

China.— Cold perspiration ; ringing in the ears. 

Cocculus indicus. — Paralyzed feeling in all the limbs, with 
trembling. 

Digitalis. — Pulse slow and irregular; cold sweat. 

Ignatia. — Much trembling. 

Nux Vomica. — Vomiting; trembling. 

Sepia. — Feet and hands cold as ice; flushes of heat. 

Stramonium. — Fainting; pale face. 

Veratrum alb. — Cold sweat upon the forehead. 

Painful Mammae— The changes which are begun early in 
pregnancy to prepare the mammae for activity, always excite 

(16) 



242 Pregnancy. 

more or less distress, sometimes amounting to real pain. The 
suffering is more intense in those cases where the breasts have 
been systematically compressed with corsets and pads. 

Inunctions with warm oil, and the application of poultices 
when the pain is severe, will afford considerable relief. 

Bryonia, when the pain is sharp and stitching, the breasts 
sensitive to touch, and the pain increased by the jar of 
walking. 

Belladonna, when there are redness, heat and induration, 
with distensive pain. 

Phytolacca, when the glandular structures seem to be in- 
volved in inflammatory action, and the pain is intense. It 
may be applied locally with additional benefit. 

Pain in the Side. — During the fourth or fifth month, and 
sometimes later, women often experience pain under the false 
ribs, on one side, or both. Nux vomica will generally relieve in 
a few days. Bryonia, belladonna, arsenicum, caulophyllnm 
or Pulsatilla may be required. 

Pain in the Abdomen. — As the result of the excessive disten- 
sion to which the abdomen is subjected, there is more or less 
pain, depending in severity on the original tenseness of the 
abdominal walls, the degree of distension and the sensibility of 
the patient. 

Inunctions of cosmoline, vaseline or some other oleaginous 
substance, is helpful. 

Sepia, if the abdominal walls are exquisitely sensitive to the 
touch. 

Conium, if there is pain in the abdomen after going to bed, 
ameliorated by rising and moving about. 

Leucorrhoea. — The wonderful physiological changes going 
on in the pelvis during pregnancy, necessitate a strong deter- 
mination of blood to this part of the body, and excite into 
activity every function. Hence, the natural secretions of the 
glands are increased in quantity, and require attention only 
when they become excessive. The secretion which appears in 
the form of leucorrhoea is mainly from the cervical glands, but 
the vaginal and vulvar glands also contribute. It is sometimes 
very copious and occasionally acrid, in which latter case the 
whole genital tract may be hot, swollen and painful. The irri- 
tation, if communicated to the urethra, will create frequent 
and painful urination. 

To control this annoying symptom, rest from sexual indul- 



Diseases and Accidents. 243 

gence, and a daily enema of tepid water, are often all that is 
required. In other cases the discharge is pertinacious. 

Pulsatilla.— The discharge is thick white mucus, and is 
extremely irritative. 

Hydrastis. — Irritative leucorrhoea, with coexisting indiges- 
tion and debility. (A mild solution of the ordinary fluid 
extract, or, what is better, the "fluid hydrastis," should also 
be used as a vaginal injection.) 

Mercurius.— Yellowish, purulent leucorrhoea, producing sore- 
ness of the parts. 

Arsenicum. — Thin burning leucorrhoea. 

Graphites. — Profuse leucorrhoea, especially in a scrofulous 
subject. 

Odontalgia.— Toothache often proves to be a real torment 
to women during pregnancy. It may set in immediately after 
impregnation, and continue, at short intervals, throughout 
pregnancy ; but in general it proves to be quite amenable to 
treatment. 

Sepia has long sustained the reputation of being the most 
serA T iceable remedy in this annoying affection. 

Belladonna, if there is determination of blood to the head, 
with either paleness or redness of the face. 

Mercurius is the remedy when the affected tooth is carous, 
the pain more severe at night and the tongue somewhat coated 
and presenting the impression of the teeth about its margin. 

Staphisagria for women with a rheumatic diathesis, teeth 
dark, carious and apparently uncared for : the pain is worse 
when the tooth is touched, especially by hot things ; also worse 
when out of doors or drawing cold air into the mouth, and 
worse at night. 

Coffea for oversensitive, nervous women, the pain sudden and 
violent, and the mental faculties active. 

Pulsatilla, when it begins in the evening and continues 
through the night > especially in women of mild temper, with 
inclination to tears. 

Nux vomica.— The pain is increased by fresh air, wine, coffee, 

cold, and mental labor, and diminished by w T armth. Shooting 

in the teeth and jaws, extending into the bones of the face and 

head, with a grinding, pressing or drawing in the decayed tooth. 

. Plant ago maj. is an excellent remedy. 

Kreosotum, that prince of remedies for toothache, should 
not be forgotten. 



244 Pregnancy. 

The selected remedy may be tried for an hour or two, but, in 
a very painful attack, if some relief is not then afforded, it 
should be exchanged for another. 

When other means for relief have failed, palliative measures 
are in order, among which are brushing the gums with spirits 
of camphor, applying equal parts of alcohol, chloroform and 
ether, use of the galvanic current, plugging a carious cavity 
with cotton saturated with a strong solution of cocaine, etc. 

There is no doubt that pregnancy predisposes to caries, and 
the latter condition of the teeth may necessitate mechanical' in- 
terference, such as extraction, filling, etc. "There is much 
unreasonable dread," says Playfair, "amongst practitioners 
as to interfering with the teeth during pregnancy, and some 
recommend that all operations, even stopping, should be post- 
poned until after delivery. It seems to me certain that the suf- 
fering of severe toothache is likely to give rise to far more 
severe irritation than the operation required for its relief, and 
I have frequently seen badly decayed teeth extracted during 
pregnancy, and with only a beneficial result." 

Cramps. — Pregnant women are often annoyed by cramps in 
the abdomen and limbs. 

Veratrum album, taken before going to bed, will generally 
prevent them. Dr. L. A. Phillips says that ammonium muri- 
aticum has, with him, proved to be almost a specific for them, 
especially those occurring in the legs. Nux vomica or coffea 
may be given to nervous, sensitive women. Secale, cuprum and 
strontiana carb. are also of benefit. Gelsemium seems well 
suited for relief of cramps in the abdomen. 

Traumatic Oomplications of Pregnancy.— Among the 
questions which confront us is that concerning the risk of 
premature expulsion of the product of conception, arising from 
traumatism, whether accidental or surgical. The chief danger 
arises from reflex effects on the uterine muscular fibers, ex- 
pressing themselves in immoderate contractions ; but there are 
other dangers, namely, destruction of foetal life from maternal 
hemorrhage, and likewise from maternal toxaemia. 

In considering the first of these risks, we ought to recollect 
that the uterus is not at rest during gestation, but is in rhyth- 
mical contraction. Throughout the greater part of pregnancy, 
this organ, as we can easily demonstrate, never wearies of con- 
tracting and relaxing, at tolerably regular intervals. Labor 
itself is but an intensification of this action. This truth being 



Diseases and Accidents. 245 

recognized, we readily see with what facility irritation applied to 
certain parts of the body may, by reflex action, augment uterine 
energy, and precipitate expulsion of the immature ovum. 

The womb, like other organs, responds much more promptly 
to irritation existing in one part of the body than in another; 
and therefore extensive traumatism can be inflicted Avith com- 
parative impunity over certain areas, while rapid effects follow 
interference with others. Then, too, in some women the reflex 
function is on the qui vive, while in others it is extremely 
lethargic. Little experimentation is required to determine that 
stimulus applied to the mammae, the external genitals, the anus, 
and the uterus itself, quickly excites the uterine muscles. Ac- 
cordingly it has been found that operations involving these 
parts are more frequently followed by abortion. 

When women are in a state of health, and free from morbid 
disposition, normal pregnancy is not easily interrupted. Mat- 
thews Duncan mentions a case, wherein an intra-uterine stem 
pessary was introduced, and worn for some time during preg- 
nancy, without exciting miscarriage. A woman seven months 
along in gestation jumped from the third story window to the 
pavement, without suffering loss of the ovum, though she broke 
both legs and both arms. Operations of all degrees of severity 
have been performed with immunity from the result in ques- 
tion ; limbs have been amputated ; ovaries have been removed ; 
the vaginal portion of the cervix uteri has been cut off, and sub- 
serous fibroids have been taken away by laparotomy. Aye, 
when women, such as the subjects of these accidents and opera- 
tions, set about procuring abortion, they, and their accesso- 
ries, are sometimes driven almost to desperation by the futility 
of their efforts. On the other hand, a slight strain, or an 
insignificant wound, in certain women, is sufficient to precipi- 
tate uterine evacuation. In a woman who has no disturbance 
of functional activity, no depreciation of vital energy, and no 
morbid predisposition to miscarriage, pregnancy is interrupted 
only by certain efficient causes operating at a favorable moment. 
To such patients irritation may be applied for a brief period, 
without harmful effect; and it seldom becomes overpowering 
unless unusually prolonged. They may fall down stairs, or 
they may be incised in vital parts, and still hold tenaciously to 
their immature progeny. But even such women will finally 
yield, though with reluctance, to the force of reflex energy set in 
action by long-continued cumulative irritation. 



246 Pregnancy. 

Again, the monthly molimen is not wholly suppressed during 
pregnancy, but only under restraint: and influences which, at 
other times, would be innocuous, are, at that particular period, 
capable of doing serious harm. For this very reason women 
with a propensity toward miscarriage, require to be held in 
check, or put into strict quarantine, at such times. But what 
can be said of those who, from a slight shock, a high step, a 
long walk or a stirring emotion, to say nothing of severe trau- 
matism, cast their untimely fruit? They make large drafts on 
our time, our patience, our ingenuity, our tact, our skill, our 
discretion and our sympathies, even in their best estate. 

Apart from reflex causes of abortion proceeding from acci- 
dental or surgical injury, we ought not to forget that uterine 
evacuation may be brought about from harm accruing to the 
foetus through maternal blood-loss, uterine congestion and gen- 
eral maternal toxaemia. Prior to the operation or injury, the 
woman may be anaemic, so that a sparing loss would so impair 
foetal nutrition, already low, as to extinguish life. Again, 
strong uterine congestion may rupture some of the finer 
decidual vessels, and destroy the functions of so large a part 
of the placenta, that foetal life can no longer be sustained. 
Finally, inasmuch as foetal blood is aerated by the maternal 
blood through the process of osmosis, it follows as a necessary 
consequence, that profound toxaemia of the mother has a 
marked effect on the unborn child. The latter can bear a certain 
degree of contamination without fatal results, but, as with us 
in vitiation of the atmosphere by poisonous gases, when that 
certain point is exceeded, it falls a prey to the baneful influence. 

To recite cases wherein serious operations were performed 
during utero-gestation, without interruption of its course, 
would profit little. They are by no means numerous in the 
practice of any one physician, and sound deductions can 
scarcely be drawn from my records, or those of any other ob- 
stetrician. Cohnstein, who devoted considerable time to the 
study of this subject, was enabled to collect sufficient data to 
establish a fair view of the danger of miscarriage, which awaits 
upon serious traumatism. He says that, in 54.5 per centum of 
all cases, pregnancy goes on to a natural termination. As 
evidence of the wonderful tolerance exhibited by some pregnant 
women, we may cite the case mentioned by Frommel, in which 
a sub-serous fibroid, with a sessile base, occupying considerable 
of the uterine wall, was removed. Convalescence was pro- 



Diseases and Accidents. 247 

tracted by iodoform poisoning, but pregnancy continued an 
uninterrupted course. The physical state of his patient, and 
her environment as well, must have been of the most favorable 
kind. 

Treatment.— Reflex effects can be greatly diminished by the 
employment of anesthetics, and, that, too, without special 
danger to the foetus. Ether is oftenest the chosen agent, but 
we are convinced that its effect on the child is more pernicious 
than that of chloroform . The latter anesthetic seems peculiarly 
adapted to the pregnant woman, and, by general agreement, 
its dangers in midwifery practice are but a remove from perfect 
safety. Then, too (and this is a consideration of some weight 
in this connection), vomiting is less likely to result from its 
administration. 

The best prophylactics are the antipsoric remedies, and, in 
our opinion, prominently, sulphur and calcarea carb. Tempera- 
ment and general physique are the best indications upon which 
to base our selections. 

Sulphur, for women of nervous temperament, inclined to 
be thin and narrow-chested. Skin rough, sense of weakness 
through the pelvis, flushes of heat and frequent faintness. She 
has a previous history of sparing flow at the month. 

Calcarea carb. — Leuco-phlegmatic temperament, fair com- 
plexion, inclined to stoutness. Clumsy; feet cold and damp. 
Previous history of profuse flow at the month. 

There are many other remedies for use before and after 
traumatism, among which should be mentioned arnica, hyperi- 
cum, caulophyllum, secale (neither of the last two lower than 
the 3 X ), Pulsatilla, arsenicum, gelsemium, china, etc. More- 
over, we would not hesitate to appeal to opium for its soothing 
effects after severe traumatism, provided there were urgent call 
for it, just as we would to chloroform or ether during the opera- 
tion. 

Under homeopathic care, both before and after operative 
procedure, the probability of uninterruption of pregnancy is 
rendered decidedly more promising. 

Constipation.— This annoying complication of the pregnant 
state owes its existence not so much to the pressure exerted by 
the gravid uterus, as to diminished intestinal action. One very 
important factor in its production is doubtless the sedentary 
habits of women at such a time. When constipation exists, 
neglect of the bowels may give rise to foecal accumulations, 



248 Pregnancy. 

sometimes of enormous size, which occasion great pain, and 
endanger premature interruption of pregnancy. If such a con- 
dition be allowed to complicate labor, it may serve as a serious 
impediment to descent of the foetus. 

Proper attention to the action of the bowels will prevent 
large accumulations, and do much to overcome the habit of 
constipation. Regularity of going to stool ought to be enjoined 
upon the woman, together with a choice of diet which will not 
include the more constipating articles of food. Fruits, in their 
season, should be recommended, graham bread, figs, and such 
other articles as are known to have a laxative effect upon the 
bowels. Sipping a half-pint or more of water, as hot as can be 
taken, thirty or forty minutes before each meal, will improve 
digestion and act as a gentle aperient. If, in spite of treatment, 
and the observance of such habits, the bowels still remain cos- 
tive, an occasional enema of water, soap and water, or olive oil 
and soapsuds, will afford temporary relief. A teaspoonful of 
glycerine, as an enema, is very effective. 

Aconite. — Much thirst ; fear of death. 

Alumina. — Scanty, hard stool. 

Agaricus m.— Loud rumbling in the bowels. 

Arnica. — Flatulency ; colic , foul smelling flatus. 

Belladonna. — Flatulency; obstruction of the bowels; much 
tendency of blood to the head ; red eyes ; intolerance of light ; 
flushed face ; heat in the head. 

Bryonia. — Much thirst; rumbling in abdomen; irritable; 
mouth and lips dry ; hard stool. 

Carbo veg. — Flatulency, with colic and rumbling in bowels. 

Causticum. — Constipation ; rumbling in the bowels. 

China. — Flatulence with colic; rumblings. 

Conium— Much vertigo. 

Graphites.— Hard stool; itching blotches about the body; 
colic. 

Ignatia. — Empty feeling at the pit of the stomach ; rumb- 
ling. 

Kali carb. — Unsuccessful desire for stool. 

Lycopodium. — Rumbling and gurgling; incarcerated flatu- 
lence. 

Mercurius. — Salivation ; gums sore. 

Natrum mur. — Hard stool; rumbling of flatus and incarcera- 
tion ; headache on awaking in the morning; aversion to bread ; 
sore places in mouth. 



Diseases and Accidents. 249 

Nitric acid.— Hard stool ; bloody stool ; much flatus. 

Nux mosch — Dryness in mouth and tongue; stool slow and 
difficult. 

Nux vom. — Flatulence. 

Opium .—Sleeplessness. 

Phos — Blood with the stool. 

Phosph. acid.— Flatulency ; stool hard. 

Plumbum.— Constipation, with colic; stools composed of 
little balls like sheep's dung ; flatulency ; colic. 

Pulsatilla.— Bloody stool. 

Sepia.— Stool difficult ; flatulency, with loud rumbling in the 
abdomen. 

Diarrhoea.— This is a less frequent complication of the preg- 
nant state. Simple looseness deserves no particular attention ; 
but frequent, watery, painful movements should be checked, as 
a continuance of them is liable to excite strong uterine efforts 
at expulsion. Light food, taken in small quantities, and re- 
pose of body and mind, ought to be prescribed. 

Pregnant women are exposed to the same influences which 
occasion diarrhoea in the non-pregnant, and, in mentioning 
a few remedies, we would not be understood- as regarding 
them peculiarly suited to diarrhoea during pregnancy, though 
we have found them very serviceable for it. They are named in 
the order of their usefulness. 

Aloes. — Feeling as if the stool could not be retained, but 
must drop involuntarily; rumbling in the bowels; generally 
good appetite. 

Alumina. — Tenesmus ; stools bloody and scanty ; urine can 
be passed onty with the stool. 

Arsenicum. — Bloody or involuntary stools; very weak, least 
motion causing great fatigue ; worse after eating or drinking ; 
great thirst. 

Bryonia. — Much better when quiet; thirst; worse when the 
weather becomes warmer. 

Chamomilla. — Nightly diarrhoea with colic; very irritable 
temper ; stool small, frequent, smelling like rotten eggs. 

Chelidonium. — Stools pasty or watery, bright yellow; lighter 
colored than usual; light red or brown. Patient craves hot 
drinks. 

China.— Stools contain undigested food ; yellowish ; painless. 
Diarrhoea worse at night, after eating and at night. 

Colocynth. — Pappy stools, with or without burning at the 



250 Pregnancy. 

anus ; may be preceded by colic ; sometimes tenesmus ; stools 
yellow, brown, bloody or greenish. 

Dulcamara. — Diarrhoea worse after every cold change in the 
weather. 

Gelsemium — Diarrhoea arising from depression or anxiety 
of mind. 

Hyoscyamus. — Frequent, slimy stools; yellow watery, pain- 
less 

Ipecac— Greenish stools, accompanied by much nausea. 

Kali carb. — Stools profuse, with much weariness or severe 
pain in lower part of abdomen ; insufficient. 

Mercurius. — Stools greenish, bloody, slimy, corrosive ; tenes- 
mus and frequent urging; perspiration. 

Phosphorus .—Stools watery ; general debility. 

Veratrum alb.— Stools profuse, watery j cold perspiration; 
colic before movement. 

Vesical Irritation. — Vesical disturbances are common dur- 
ing pregnancy. They are more marked during the early and 
the latter parts of the term : the former due chiefly to hyper- 
semia of the pelvic organs which characterizes that stage of 
gestation, and the latter proceeding in great part from the 
mechanical compression exerted at that time. The symptoms 
are frequent desire to urinate, with pain, burning, and some- 
times itching. 

If the ailment becomes distressing, and treatment proves 
unavailing, an examination per vaginam should be made, and 
if the difficulty proves to owe its existence to mechanical causes 
which can be remedied, careful interference may be practiced. 
When there is nothing more than irritation, and the desire is 
frequent and distressing, we have often used a steel sound, of as 
large size as the meatus can easily receive, with excellent effect. 

Treatment. — This ailment is sometimes so distressing that 
we feel justified in giving here a brief repertory of symptoms : 

DISCHARGE OF URINE. 

Difficult, aeon., alum., apis, arg. n., am., From atony, camph., opium, rheum, 

ars., aur., benz. ac, cactus, camph., secale, thuja. 

can. ind., can. sat., caps., crot., dulc, From cold, cold drinks, dulc, nit. ac. 

erig.,eup. purp., gels.,helon.,hepar s., From spasmodic contraction of the. 

hyos., lith. c, lye, mag. m., meph., neck of the bladder, hyos. 

mere, mur. ac, nat. m., nit. ac, After dinner and supper, nux m. 

nux m., opium, pareira, plumb., ran. After exertion, nux m. 

b., rheum, rhus t., secale, sepia, All day, meph. 

stram., sulph., tereb., thuja, zincum. Especially in the morning, sepia. 



Diseases and Accidents. 



251 



DISCHARGE OF URINE — CONTINUED. 



With pain and heat, nit. ac 

With urging to stool, nux m. 

Can pass only by straining at stool, 
alum. 

Must press so that anus protrudes, 
mur. ac. 

Alternate dysuria and enuresis, gels. 

Diminished, hyper., kreos., led., lob., 
mex., pod., rhus, sab., senega, stram., 
sulph. ac. 

Dribbling, agar., am., benz. ac, brom., 
bry., can. ind., caust., kali brom., 
nux v., petr., plumb., selen., spig., 
stram. 

During motion, without sensation, 
bry. 

At beginning of stool, kali b 

After stool or urine, selen. 

After urinating, can. ind. 

With burning after urinating, brom. 

With burning at meatus, spig. 

No pain, sars., stram. 

In spite of urging no stream forms, 
stram. 

In Drops, aeon., apis, am., bry., cactus, 
camph., canth., caust., clem., colch., 
dros., dulc, eup. purp., hell., lachn., 
mere, mere, c, nux m., nux v., plumb., 
puis., rhus, sabina, sars., sep., spig., 
staph., stram. 

Sensation as if drops came from 
bladder, sep. 

When moving, without sensation, 
bry. 

When sitting, puis. 

When walking, puis. 

With frequent desire, apis, eup. 
purp. 

With much burning, cactus, nux v. 

With great pain, mere. c. 

With tearing, nux v. 

Increased, acet. ac, aeon., agn., amb., 
berb., calcp., carbo a., carbo v., caul., 
cic, cina, colch., eup. purp., euph., 
hell., hyd., kali j., kob., led., HI., lob., 
mag. c, nice, marum., mere j. r., 
mere c, nat. m., phos.,puls., rheum, 
rhod., senega, squill., tell., ther., ustil., 
valer., verat. v. 



With headache and profuse sweat ; 
vomiting, aeon. 

With sense of weakness, cale p. 

With unquenchable thirst, kali j. 

With thirst for large quantities, 
nat. m. 

With sweat on head, hands and feet, 
or forepart of body, phos. 

Interrupted, carbo a., clem., con., led., 
meph., op. 

With burning during the interrup- 
tions, clem. 

From spasm at neck of bladder, op. 

Painful, aeon., sese, apis, aur., bapt., 
calad., camph., can. ind., can. sat., 
canth., caps., crot., dulc, orig., eup. 
purp., fluor. ac, gels., hell., helon., 
lith. c, lye, mag. c,mere c, mur.ac, 
nat. e, nat. m., nat. s., nit. ac, nux m., 
nux v., olean., pareira, plumb., ran. 
s.,sab., sars., tereb. 

After cold drinks, dulc 
Dinner and supper, nux m. 
Exertion, nux m. 
Jolting ride, eup. purp. 

Alternating with enuresis, gels. 

Irritating, sars. 

Very, eup. purp., pareira. 

With heat, nit. ac. 
Micturition, vomiting and purging 
from spasmodic contractions, 
crotal. 

Profuse, acet. ac, act., seth., agar., aloe, 
alum., amm. c, amm. m., arg., ars., 
aur., bary. c, bell., bis., bry., cact., 
cole p., can. ind., cepa, chel., cic, 
coff., col., cycl., crotal., dros., erig., 
eup. perf., eup. purp., euph., ferr., 
gels., glon., guai., ham., hell., helon., 
ign., iris, kali b.,kali c, kali j., kalm., 
kreos., lith. c, mang. acet., mere j.fl., 
mez., mur. ac, nat. a., nat. m., olean., 
oxal. ac, phos., phos. ac,phyt.,rumex, 
sab., samb., sang., sars., selen., sil., 
spig., stan., staph., stram., sul.,tarax., 
tereb., thuja, verat. a., vibur., xanth. 

During night, amm. m., arg. m. bary. 
c, phos. ac, sang., sars., stram., 
sulph. 



252 



Pregnancy. 



DISCHARGE OF URINE — CONTINUED. 



Disturbing sleep, lith. c 
In afternoon, rumex. 
In morning, ambra, mez. 
Followed by dull pain in region of 

kidneys, ambra. 
Nervous affections, alum. 

Nervous women, xanth. 

Spasms, stram. 
Passed without sensation, sars. 
Pale, eup. perf. 

Relieving backache, gels., lye. sil. 
Very often, euph. 
Very profuse, eup. purp., hell. 
With frequent discharge, ars. 

Headache, verat. a., vibur. 

Hysteria, sulph. - 

Sense of weakness, calc. p.,ferr. 

Thirst for large quantities, nat. m. 
Retained, aeon., apis, apoc, am., ars., 

arum, aur., bell., benz. ac, camph., 

canth., caust., cic, dulc, ham., hell., 

hepar, hyos., illic, laur., millef., op., 

puis., rhus, ruta, sab., sec. 
After exertion, am. 



From atony, muscular, hell. 
Cold, aeon. 

Contraction of sphincter, op. 
Exertion, am. 

With backache, rhus. 
Constipation, canth. 
Pain, canth., ruta, sars. 
Pressure in bladder, aeon. 

Scanty, abrot., aeon., act., sesc., ailan., 
aloe, alum., ant. t., apis, apoc, am., 
ars., arum, aur., bapt., bell., berb., 
brom., bry., camph., canth., card, 
mar., cham., china, clem., cocc, colch., 
crotal., cup., cycl., dig., dros., dulc, 
eup. perf., eup. purp., fluor. ac, 
graph., ham., hell., hyos., hyper. ,ipec, 
iris, kali b., kali brom., kali c, kob., 
HI., lith. c, lye, mere. j. fl., mere, c, 
mur. ac, myrica, nat. s., nit. ac, nux 
m., op., petr., phos., phyt., psor., 
ptelea, puis., ruta, sang., sars., selen., 
squill., stann., staph., tereb., ustil., 
verat. a., verat. v. 

With no uneasiness, apoc. 



WHEN NOT URINATING. 



Burning pain in forepart of urethra, 
which compels to urinate, can. 
sat. 

Cutting in urethra between micturi- 
tion, with frequent urging, mang. 
acet. 



Cutting and stinging in urethra, 

caps. 
Fleeting pain in bladder, benz. ac. 
Pressure in forepart of urethra as if 

to urinate, can. sat. 
Stitches along urethra, can. sat. 



BEFORE URINATING. 



Aching in back, ameliorated by 
urinating, lye 
In bladder, fluor. ac 
Bladder, aching in, fluor. ac 

Burning in, fluor. ac, rheum. 
Bladder, burning in and cutting, 
from neck of to fossa navicu- 
laris, canth. 
Pain in region oi,phyt. 

Worse in right, flashes of, lith. c. 
Pressure on, nux v. 
Burning in kidneys, rheum. 
In bladder, can. ind., canth., clem., 
fluor. ac, rheum. 



In bladder, from neck to fossa 

navicularis, canth. 
In urethra, can. ind., can. sat., 

canth., clem., fluor. ac. 
Cutting from neck of bladder to fossa 

navicularis, canth. 
Kidneys, burning in, rheum. 
Pressure on bladder, nux v. 
Stinging in Uretha, can. ind. 
Ureters, violent pain in direction of, 

chel. 
Urethra, burning, can. ind., canth., 

clem., fluor. ac. 



Diseases and Accidents. 



253 



DURING URINATION. 



Abdomen, pain in lower, agn. 
Aching of back, ant. c 
Anus prolapsed, mur. ac. 

Constriction of neck of, cactus. 
Pain in, ant. t., phyt. 

Violent, ant. t. 
Pressure in, lachn. 
Smarting and burning in, eup. 

purp. 
Spasm in, asaf., op. 

Interrupting flow, op. 
Stitches in, nat. m. 
Tenesmus of, lith. c. 
Throbbing in neck of, during 
straining to urinate, dig. 
Burning in kidneys, rheum. 
In bladder, ?ham., eup. purp., 
rheum. 
And smarting, eup. purp. 
Neck of, canth., cham. 
And cutting to fossa navi- 
cularis, canth. 
In urethra, aeon., aloe, ant. c, ant. t., 
arg. n., ars., bapt., cact., calc, can. 
ind., can. sat., caps., carbo an., 
caust., cham., clem., eup. purp., 
glon., helon., hepar, ign., kali b., 
kali c, lachn., mag. c, mere, c, 
mur. ac, nat. e, nat. m., nat. s., 
nice, nit.ac, nux m., nux v.,psor., 
rheum, sab., staph., thuja. 
And soreness, carbo a. 
With gonorrhoea, thuja. 
"With discharge of urine in 
drops, cact. 
In meatus urinarius, can. sat., 
cinch., puis., sep., sulph. 
And smarting backwards, can. 

sat. 
During bloody urine, puis. 
Chills, rigors, stram. 
Constriction of neck of bladder, 

cact. 
Cutting in urethra, ant. c, caust., 
guai., mur. ac, nux m., op., psor. 
Haemorrhoids protrude, kali c. 
Kidneys, burning in, rheum. 
Meatus urinarius, burning at, during 
bloody urine, puis. 



Itching at, preceded by urgent de- 
sire, petr. 
Pain in hips, berb. 
Thighs, pareira. 
Kidneys, agn. 

Burning, rheum. 
Bladder, ant. t., phyt. 
Urethra, calad., lith. c 
Pain in urethra at meatus, zing. 

Glans penis, oxal. ac. 
Pressure in bladder, lachn. 
Prolapsus ani, mur. ac. 

Recti, valer. 
Rigors, stram. 

Shuddering along spine, nit. ac. 
Smarting and burning in bladder, 
eup. purp. 
In urethra, colch., eup. purp., graph., 
ign., kob., mag. c, mere c. nat. m., 
nit. ac, ptelea, sep. 
Of vulva, nat. m. 
Soreness in urethra, carbo a., hepar, 

ign. 
Spasm in bladder, asaf. 
In neck of, interrupting flow, 
op. 
Stitches in bladder, nat. mur 

Urethra, can. sat., graph. 
Stool, ailan., aloe, alum., canth., mur. 
ac, squill. 

Urging to, aloe, alum., canth. 
Straining and prolapsus recti, 

valer. 
Tearing in urethra, nux v. 
Tenesmus of bladder, lith. c 
Thighs, pain down, pare ira. 
Throbbing in neck of bladder during 

straining to urinate, dig. 
Urethra, burning, aeon., aloe, ant. c, 
ant. t., arg. n., ars., bapt., cact., 
calc, can. ind., can. sat., caps., 
carbo a., caust., cham., clem., eup. 
purp., glon., helon., hepar, ign., 
kali b., kali c.j lach., mag. c, mere 
c.j mur. ac, nat. c, nat. m., nat. s., 
nice, nit. ac, nux m., nux v., 
psor., rheum, sab., staph., thuja. 
Cutting, ant. c, canth., guai., mur. 
ac.j nux m.j op., psor. 



254 



Pregnancy. 



DURING URINATION — CONTINUED. 



Smarting, colch., eup. purp.. graph., 
ign. t kob., mag. c, mere. c,nat. m., 
nit. ac, ptelea, sep. 
As if raw, colch. 

Stinging, can. ind. 



Urethra, stitches, can. sat., graph. 

Tearing, nux v. 
Urging and prolapsus recti, valer. 
Varices protrude, kali c. 
Vulva, smarting and soreness, nat. m. 



AFTER URINATION. 



Aching of back, relief after, lye. 
Bladder, aching in, fluor. ac. 

Sense of fullness continues, dig.t 

eup. purp., ruta, staph. 
Spasmodic in neck of, extending to 
thighs, puis. 
Burning, ant. t., brom., can. sat., 
canth., caps., con., fluor. ac, iris, 
kali b., kali c, led., mag. m., nat. c, 
nat. m., staph. 
And cutting from neck to fossa 

navicularis, canth. 
With dribbling, brom. 
Cutting, canth., lye, nat. m. 
Desire continues, berb., bov., senega, 

siann., staph. 
Fullness in bladder, sense of, con- 
tinues, dig., eup. purp., ruta, 
staph. 
Even after frequent urination, 

eup. purp. 
And feeling as if moving up and 
down at every step, ruta. 
Headache, relieved by profuse uri- 
nation, gels., sil. 
Jerking and cutting in urethra, lye. 
Lancination in abdomen, relief from, 

carbo a. 
Pain, severe, sars. 

Spasmodic, in neck of bladder, ex- 
tending to thighs, puis. 
Sexual organs excited and sense of 
weakness, berb. 



Shooting to abdomen, tar ax. 
Soreness in urethra, carbo a., hepar, 

ign. 
Spasmodic pain in neck of bladder, 

extending to thighs, puis. 
Spasm of bladder, asaf. 
Stitches and lancination in abdo- 
men, relief from, carbo a. 
Urethra, burning, ant. t., brom., can. 
sat., canth., caps., con., fluor. ac, 
iris, kali b., kali c, led., mag. m., 
nat.c, nat. m., staph. 
In glandular portion, continu- 
ing long after, kali b. 
Cutting, canth., lye, nat. m. 
Drop remained, sensation as if, arg. 
n., kali b. 
Eunning down, thuja. 
Jerking, lye 

Smarting, borax, caps., HI., ptelea. 
Stinging, can. ind. 
Stitches, kali b. 
Straining, mur. ac 
Tenesmus, mur. ac, nit. ac 
Urging, mur. ac, nit. ac. 
Urging continues, berb., bov., senega, 

stann., staph. 
Urine were still flowing, sensation 

as if, vibur. 
Weakness and dullness relieved 
after, tereb. 
Sense of, and excitement of, 
berb. 



Cough. — In addition to the more common diseases of the 
respiratory tract, from which pregnant women are not exempt, 
there is a spasmodic cough, doubtless of reflex origin, which 
sometimes proves most distressing. It bears a resemblance to 
whooping-cough, and may become so violent, and the par- 
oxysms so frequent, as to excite abortion. 



Diseases and Accidents. 255 

Aconite for a few days, followed by nux vomica, has proved 
efficacious. If the cough is worse in the evening and night, 
belladonna. If attended with vomiting, ipecac. Cimicifuga 
and sepia are sometimes indicated. Other remedies are bryonia, 
phosphorus and coniuw. 

Dyspnoea. — Oppressed respiration, not always amounting 
to real dyspnoea, may arise from reflex causes, but real diffi- 
culty of breathing most frequently proceeds either from upward 
pressure of the uterus, or from heart disease. 

When it is clearly a reflex condition, moschus, nux moschata 
and lobelia are likely to afford aid. Nux vomica in these and 
other cases, on special indications, will be found of service. 
When dependent on heart disease, strophanthus, digitalis and 
cactus are better remedies. We have recently given great relief 
in a case of mitral insufficiency, by the use of spongia. 

Sleeping with the head and shoulders elevated will be found 
to have an ameliorating effect on the distress. 

Hemorrhoids. — Pressure of the gravid uterus on the hem- 
orrhoidal veins, accompanied, as it often is, by a loaded rectum, 
ultimates with facility in the production of piles. Coincidently 
with this dilatation of the rectal veins, varices in other parts, 
such as the vulva, vagina and lower extremities, are often ob- 
served. Distension may become so great as to produce rup- 
ture, giving rise to vaginal or vulvar thrombus or hematocele, 
a condition which will be described in another place. The hem- 
orrhage resulting from such an accident is sometimes profuse. 

Hemorrhoids may be kept within bounds, and thus much 
suffering averted, by securing, without the use of purgative 
remedies, a daily movement of the bowels. Much can be done 
to favor this, as observed under the head of "constipation," 
by regular efforts at stool. 

Belladonna. — Piles so sensitive that the woman cannot bear 
to have them touched ever so lightly ; the back feels as though 
it w T ould break ; throbbing headache. 

Aloes.— The piles protrude, and are not and sore, attended 
with bearing-down sensations. 

Hamamelis. — Bleeding hemorrhoids, with burning, soreness, 
fullness and weight, with tendency to rawness. The local use 
of the aqueous extract is very beneficial. 

Nux vomica. — Is of greatest service to women of sedentary 
habits, and those who have been accustomed to the use of 
cathartics. 



256 Pregnancy. 

Sepia.— The piles come down with even a soft stool ; feeling 1 
of bearing- and straining in the rectum; oozing of moisture from 
the rectum ; soreness between the nates. 

Sulphur. — It is suitable to piles of all descriptions, and 
should be given when any of its general characteristic symp- 
toms are found. 

Collinsonia. — This is one of the best remedies. Sensation as 
of sticks, sand or gravel, in the rectum. Worse in the evening, 
better in the morning. 

^Esculus hipp. — Blind and painful hemorrhoids, sometimes 
slightly bleeding; severe pain across the back and hips; feeling: 
as of a stick in the rectum. 

Other remedies sometimes required are, aconite, apis, alu- 
mina, calcarea carb., graphites, leptandria, nitric acid, Pul- 
satilla. 

An operation for radical cure of hemorrhoids during ges- 
tation is not advisable; but should they remain permanently 
protruded after the puerperal period has passed, they may 
be excised, with proper precautions, or otherwise cured. 

Varices. — The veins of the lower extremities, in certain 
women, become varicose, and sometimes painful. When this 
is true, an elastic stocking gives considerable comfort. 

A varicose condition of the vulva can be kept in check by 
the moderate pressure of a soft pad held by a T bandage. 



Diseases of Pregnancy. 257 



CHAPTER XI. 

DISEASES OF PREGNANCY— Continued, 

Displacements of the Gravid Uterus.— The gravid uterus 
is liable to displacement, and the occurrence forms one of the 
serious complications of pregnancy. 

Anteversions and Anteflexions. — There is much to be 
found in homeopathic literature on this subject, and one would 
be led to suppose that it is not only a common occurrence 
during pregnancy, but that it is a frequent and serious compli- 
cation of labor. This error proceeds from a want of clear 
comprehension of the normal inclination of the longitudinal 
uterine axis. The plane of the 
pelvic brim lies at an angle of 
about 60° with the horizon, 
and it is generally supposed 
that the long uterine axis is 
coincident with, or lies parallel 
to, the axis of this plane, which 
would give the fundus uteri, as 
is seen in the figure, an incli- 
nation forward more marked Fig. 121.— Relative size and in- 
than many suppose. The nor- clination of the Uterus at the close 
mal anteversion of the impreg- of Gestation, 
nated uterus is, at first, sometimes exaggerated by the increased 
weight of the gravid uterine body, but the deviation is usually 
rectified by the gradual development, and upward movement, 
of the organ. In rare cases the deviation continues after the 
fourth month, and produces tenesmus of the bladder, dysuria, 
or incontinence. The condition, when once recognized, is 
readily overcome with, or without, an abdominal supporter. 
A pessary would be of no service. 

A similar position of the uterus in late pregnancy forms 
what is known as pendulous abdomen, which is referable to 
inadequate abdominal support, proceeding from relaxation of 
the parietes, separation of the recti muscles, or to the cicatrices 
left from operations or injuries. Curvature of the spine, and 
contracted pelvis, favor its production. Cases are on record 
wherein the recti muscles were separated, and the uterus was 
(17) 




258 



Pregnancy. 



anteverted between them, covered only by fascia and integu- 
ment, nearly to the knees. 

Treatment clearly consists in the reduction of the displace- 
ment, and the application of a firm abdominal bandage. 

Ketro version.— This is now regarded as a comparatively in- 
frequent form of uterine displacement during pregnancy, and 
when spontaneous rectification does not occur, the development 
of the organ forces it into a flexed condition. 

Ketroflexion. — This is an uncommon occurrence in women 
for the first time pregnant. It may arise during pregnancy 




Fig. 122. — Retroflexion of the Gravid Uterus. 



from the same causes which produce it in the non-pregnant 
state, such as a fall, or undue distension of the bladder and 
rectum ; but sometimes it is doubtless due to displacement of 
the organ which antedates conception. 

With the advance of pregnancy the ufcerus generally 
straightens and clears the pelvic brim, without serious incon- 
venience. This spontaneous rectification is not so apt to occur 
in chronic cases as in recent ones, because tissue tonicity is 
greatly impaired. In many cases the fundus does not ascend 
above the sacral promontory at the usual time, but remains 
incarcerated in the pelvic cavity, when the condition which was, 



Diseases of Pregnancy. 259 

perhaps, at first, one of retroversion, now becomes partial re- 
troflexion, by means of which the uterine cavity is divided into 
diverticuli or pouches — an anterior and a posterior. 

The symptoms of incarceration embrace dysuria, or even 
complete retention, vesical tenesmus, incontinence of urine, 
painful defecation, constipation or obstipation, severe sacral 
and lumbar pains extending into the thighs. In grave cases, 
emesis, and all the other sj'mptoms of ileus, may be developed. 
At any time during incarceration, abortion may occur, followed 
by relief of the threatening symptoms ; but should it persist, 
metritis, parametritis and peritonitis may ensue with fatal 
result. Death may also result from pathological processes set 
up in the bladder by retention and decomposition of urine. 
These are cystitis and gangrene, which, in turn, give rise to 
septicsemia or vesical rupture. The retention may lead to 
ursemic poisoning, and thus to death. 

The diagnosis of retroflexion and incarceration of the uterus 
is not often difficult. As the physician passes his finger along 
the vagina, in order to reach the os uteri, he will find that it 
impinges upon an elastic swelling along its posterior and supe- 
rior border, lessening and changing the course of the latter, 
and if pregnancy be advanced to the fourth or fifth month, 
completely filling the cavity of the lower, or true pelvis. The 
cervix uteri, if discovered, will be found behind or above the 
posterior or inner face of the symphysis pubis. On abdominal 
examination, the fundus uteri cannot be felt above the pelvic 
brim. By bimanual examination, the alternate relaxation 
and contraction of the gravid uterus can be made out, and 
differentiation thus made between the body and fundus of the 
uterus and a swelling of a different kind in the same situation. 
The clinical history of the case will also give important data. 

The distinction between an incarcerated uterus and an 
extra-uterine pregnancy is sometimes difficult, necessitating a 
thorough and careful bimanual examination, aided, in cases 
of abdominal tenderness, by the employment of an anes- 
thetic. 

Treatment .—In these trying cases delay is dangerous, owing 
to the progressive increase in size of the uterus, and the per- 
nicious effects of long-continued pain and physical disturbance. 
The object to be held in view, is a return of the fundus uteri to 
a situation above the pelvic brim. But before attempting the 
operation there are certain preliminaries to be observed, the 



260 Pregnancy. 

first of which is thorough evacuation of the bladder and rec- 
tum. For the purpose of drawing the urine there is no instru- 
ment superior to the soft rubber catheter, of small size, as the 
urethra is too greatly altered in its course and calibre by the 
compression to which it is subjected to admit of the safe use of a 
stiff catheter. Even with this instrument we may sometimes 
utterly fail, in which case puncture of the bladder, if distension 
exists, may be practiced above the symphysis pubis by means 
of a small needle of the aspirator. 

Another preliminary to the operation in cases of real uterine 
incarceration is the induction of anesthesia, and the placing of 
the woman in the Sims' latero-prone position. The knee-chest 
position should be prescribed if no anesthetic is used. The 
operation itself is performed by introducing four fingers into 
the rectum, and pushing upwards on the fundus uteri. Dr. 

Barnes recommends 
turning the fundus 
to one side, so as to 
avoid the sacral pro- 
montory. Repeated 
efforts may have to 
be made to achieve 
complete success. 
Mere evacuation of 
the bladder and rec- 
tum, and the influ- 

-Soft rubber Catheter. ence of gravity 

brought to bear 
through the assumption of the knee-elbow, or knee-chest posi- 
tion, will be adequate in some cases to bring about complete 
reduction. This result may be still further promoted by retrac- 
tion of the perineum with the fingers or by Sims' speculum, 
and the admission of air into the vagina. 

An instrument has been devised by Dr. H. N. Guernsey, 
which serves an admirable purpose in the accomplishment of 
difficult reduction. It consists of a curved rod of steel, upon the 
end of which is a hard smooth ball, about three-fourths of an 
inch in diameter. The instrument is provided with a suitable 
handle. f 'As soon as a case of this form of displacement is 
clearly diagnosed," says the Doctor, "if the urine or faeces are 
retained, the usual means should be at once adopted for their 
evacuation. The patient should then be placed on the bed, 




Diseases of Pregnancy. 261 

near its edge, upon her knees and elbows, so that the force of 
gravity may assist in the reduction. The ball of the instru- 
ment, well lubricated, is to be brought to the anus, with the 
convex surface of the rod upwards, then gently pressed till 
within the sphincter, when the handle should be slightly ele- 
vated, so as to bring the ball against the anterior wall of the 
rectum. The instrument is now to be firmly and carefully 
pressed up the rectum, when the ball wf elevate the fundus, 
care being taken to raise the handle of the instrument more 
and more as progress up the rectum is made; and presently the 
uterus will regain its normal position immediately posterior to 
the symplrysis pubis." 

It has been recommended that a Hodge pessary of large 
size be introduced into the vagina, after reduction of the disloca- 
tion, and allowed to remain until the uterus has reached a 
size which precludes the possibility of a return to its former 
position. Others advise simple lateral decubitus, without the 
use of a pessary. The after-treatment includes also careful 
attention to the bladder and rectum, neither of which should 
be permitted to become loaded. 

It occasionally happens that replacement of the uterus is 
prevented by inflammatory adhesions, or by the secondary 
swelling of the displaced organ, in which case the induction of 
abortion is the only recourse. Mechanical obstacles to the 
ordinary methods of arousing uterine action are here met, and 
the accomplishment of the object in a tolerably safe manner 
will tax one's ingenuity and skill. The introduction of a 
uterine sound, or a flexible catheter, is rarely practicable. Dr. 
P. Miiller, in a case of complete retroversion, resorted to the 
following ingenious expedient, a knowledge of which may be of 
benefit to others. He cut off the end of a male silver catheter, 
and after having bent the extremity, he hooked it within the 
cervix uteri, which was looking upwards and forwards. Through 
this artificial channel he passed a piece of catgut, and left it 
between the membranes and uterine wall. In twelve hours the 
foetus was expelled. If our efforts to pass a foreign, but in- 
nocuous, substance within the uterus prove unavailing, the 
organ may be punctured through the vagina with an aspirator 
needle, or a fine trocar, and a portion of the liquor amnii with- 
drawn, with but slight risk to the woman, if done under 
strict antiseptic precautions. This is a sure method of bring- 
ing on abortion. 



262 Pregnancy. 

Prolapse of the Uterus.— We have already directed atten- 
tion to the normal descent of the gravid uterus during the 
early weeks of gestation ; but we have now to mention the 
descent beyond the physiological bounds there described, when 
it becomes pathological. Hiiter, who, in 1860, collected all the 
recorded cases, makes the following division : 

1. The gravid uterus being prolapsed, reduces itself during 
the first months, and pregnancy and labor follow their usual 
course : 5 cases. 

2. The prolapse is not spontaneously reduced. Its artificial 
reduction and support must be undertaken : 8 cases. 

3. Reduction cannot take place, because of incarceration: 
3 cases. 

4. The prolapse causes labor before term : 7 cases. 

5. Prolapse occurs in the second half of pregnancy, and per- 
sists to term and during labor : 3 cases. 

6. Prolapse occurs just before or during labor as term. In 
such a case, prolapse may not have existed prior to labor, or, 
if it did exist before, was spontaneously reduced during early 
pregnancy; or the prolapse was reduced and the uterus sup- 
ported by a pessary : 16 cases. 

7. Prolapse occurs during pregnancy and labor: 15 
cases. 

8. Prolapse existed before impregnation, but became pro- 
nounced during labor : 16 cases. 

These give a total of 73 cases. 

In women predisposed to prolapsus, the condition is easily 
brought about in the early weeks of pregnancy. In those cases 
wherein prolapsus existed before impregnation, the condition 
may not only continue, but become aggravated during early 
gestation. It is found to exist more frequently in multigravidse 
in whom the process of uterine involution after former labors 
had not become complete. A prominent exciting cause is trau- 
matism, under the power of which great strain is put upon the 
natural uterine supports. 

The disturbances to which this sort of displacement gives 
rise, vary in severity and character with the stage of pregnancy 
at which it occurs. Should the condition remain unrectified, 
the bladder and rectum become irritated, and there is a feeling 
of weight in the anus, and of painful tractions in the groins, 
lumbar region and umbilicus. A foetid discharge is set up, 
change of position does not relieve the suffering, and a state of 



Diseases of Pregnancy. 263 

marasmus is liable to supervene. An intensification of these 
symptoms goes on until abortion ensues. 

Procidentia is sometimes simulated by cervical hypertrophy. 
When this involves the intra-vaginal portion, the elongated 
neck may, from its mere length, be forced downwards to such 
an extent, that the os will lie between the labia, and there be 
subjected to constant friction and atmospheric irritation. The 
result can easily be predicted. In view of the prognosis under 
these circumstances, and considering the prejudicial influence 
which such a pathological state would naturally have on the 
woman's general health, as well as the pregnancy itself, cervical 
amputation has sometimes been practiced, without interrup- 
tion of pregnancy. 

Prolapsus usually rectifies itself as pregnancy advances; but 
it may, in many cases, be thought best to elevate the womb 
from time to time with the finger, but always in a most gentle 
manner. Such treatment, if followed by a season of rest in 
bed, will be found most serviceable. 

When prolapse is complicated by vesical distension, it may 
be necessary to use the catheter for temporary relief; but this 
instrument ought to be discarded if simple expedients can pos- 
sibly be made to accomplish the desired end. 

When the developing uterus becomes incarcerated in the pelvic 
cavity, in a state of prolapse, the condition is somewhat like 
that of incarceration with retroversion or retroflexion. If un- 
relieved, abortion is sure to ensue, and therefore reasonable, 
but not violent, attempts should be made to push it above the 
pelvic brim. If such efforts are not attended with success, 
abortion ought to be artificially induced before the tissues have 
been long compressed. 

Cardiac Diseases.— We have elsewhere noted the circula- 
tory changes incident to pregnancy, prominent among which 
are alterations in the relative constituents of the blood, the 
fibrin being increased and the red corpuscles diminished, while 
the total quantity of blood is greatly augmented. We should 
here allude also to cardiac hypertrophy and increased arterial 
tension. Accordingly we are not surprised to observe that 
pregnancy appears to hasten the development of cardiac 
lesions. The latter vary in seriousness with their form. Myo- 
carditis interferes with the development of cardiac hypertrophy, 
compensatory for the increased blood supply and, in some 
instances, pre-existing valvular lesions. Endocarditis shows a 



264 Pregnancy. 

strong tendency to assume the fatal ulcerative form, while 
pericarditis has no marked effect on the normal course of utero- 
gestation. The chief danger in these cases lies in the direction 
of interference with the necessary hypertrophy which pregnancy 
imposes; while another element of danger is found in the 
rapidly changing degrees of vascular pressure brought about 
during labor, by intermittent uterine and general muse alar 
action. 

The early weeks of pregnancy are comparatively free from 
indications of cardiac disturbance; but when once developed 
it rapidly augments in intensity, and the woman thus afflicted 
rarely goes to term. The distressing symptoms point to 
pulmonary congestion and oedema, — occasionally to pneumonia 
and pleurisy. The most serious valvular lesions, here, as in 
the non-pregnant state, are 1. Mitral stenosis, and 2. Aortic 
insufficiency. In those cases wherein the pathological con- 
ditions have developed during pregnancy, when once the 
disabled heart has weathered the storm of parturition, the 
abnormal symptoms usually subside ; but, when pregnancy has 
merely aggravated pre-existing disease, the patient is extremely 
liable to sink during the puerperium. This latter clinical fact 
was recently made peculiarly impressive to us by the death of a 
patient, three days after delivery of two seven-months foetuses, 
in whom there was decided tricuspid insufficiency. 

Women who are the subjects of serious cardiac lesions ought 
not to be encouraged to marry. 

The existence of pregnancy will not materially modify the 
treatment of these cases. The patient must have plenty of fresh 
air and good food, but excesses in both should be scrupulously 
avoided. 

In our medication we should select remedies mainly from 
among the antipsorics, and the patient's early history should 
be carefully scrutinized for indications. 

These diseases constitute no contra-indications for the use 
of anesthetics, though they ought to be given with unusual 
caution. 

Eruptive Fevers.— Measles is infrequent, not more than 
two-score of cases having been reported. In those instances 
where they did not appear, they manifested a strong tendency 
to become hemorrhagic, and to excite metrorrhagia which 
terminated fatally to both mother and child. Pneumonia 
is a frequent and dangerous complication. Abortion nearly 



Diseases of Pregnancy. 265 

always takes place. The mortality arising from this disease is 
high; but attacks occurring in the early months are not as 
dangerous as those encountered at a later period. 

Variola, among eruptive fevers, is the most frequent and 
dangerous of them all. The dangers arising from an attack 
are augmented as the woman advances in pregnancy, hence we 
may regard it as a fortunate clinical fact that the disease shows 
a preference for the early months. The ordinary perils of such 
an attack are here increased by a strong tendency to abortion 
and profuse hemorrhage. The disease itself may, after abor- 
tion, assume a hemorrhagic type. The more severe forms of 
the disease prove almost invariably fatal to both mother and 
child. In one series of twenty-nine cases of all degrees of severity, 
tabulated by Meyer, five died and nine aborted. In another 
series of forty-seven cases, eighteen died and twenty-two 
aborted. When the disease assumes a mild, or discrete, type, 
its course is generally favorable, though abortion often en- 
sues. 

'Scarlatina. — Cazeaux never saw a case of this disease in a 
pregnant woman. Olshausen, after thorough search, was able 
to collect only seven cases while he found one hundred and 
thirty-four in puerperal. A striking peculiarity of the disease 
as it appears in connection with the pregnant state, is its long 
period of incubation. The disease, under other conditions, 
displays peculiar whims in this respect ; but, in some instances 
where it has appeared in pregnancy and puerperality, the lapse 
of time between exposure and development has been astonish- 
ingly great. For instance, a woman in the early months may 
be exposed to the contagion, and temporarily escape its 
baneful influence at the time only to fall a prey to the disease 
in the puerperal state. 

As a result of the disease in pregnancy, miscarriage always 
takes place, and, in the larger number, death ensues. 

Apart from the management of threatened or accomplished 
abortion, the disease requires treatment, differing in no essen- 
tials from that of other cases. 

Continued Fevers. — Typhoid.— Pregnancy does not exempt 
from attacks of the various continued fevers, nor does it seem 
seriously to modify their course, save in the one particular of 
added miscarriage. Out of seventy-two cases of typhoid fever, 
sixteen aborted ; and out of sixty -three cases of relapsing fever, 
pregnancy suffered interruption in twenty-three. 



266 Pregnancy. 

As in the eruptive diseases, so here, these fevers are more 
likely to attack women in the early part of the term. Foetal 
dangers, arising through abortion, are sufficiently expressed 
in the figures just given ; while the maternal perils are increased 
chiefly by the abortion which is so liable to ensue. In serious 
types of the diseases, danger is augmented by the uterine hem- 
orrhage which may occur without immediate interruption of 
pregnancy. 

No special observations concerning treatment are necessary, 
excepting to notice the unusual demand for the tampon in view 
of the greater danger of excessive hemorrhage, and the in- 
creased difficulty of controlling it. 

Malarial. — The revulsive effect of pregnancy brings out 
latent dyscrasise and lurking poisons, malaria among the 
number; yet the organism, at such a time, does not seem to be 
a fertile soil for its development. When malarial symptoms 
are manifested, their paroxysms assume either an anticipating 
or a retarding tendency, being very irregular in appearance. 
Karely the type is pernicious in character. Even though pro- 
tracted in its stay, malarial fever seldom results in abortion. 
When labor supervenes during the fever, the paroxysms may 
be temporarily interrupted, only to return a few days post- 
partum . The interruption is not infrequently for a longer period. 

Arsenicum. — This remedy is one of the most valuable, espe- 
cially in cases of ancient infection. We find it peculiarly suited 
to the irregular type of the disease. 

Natrum m— In the 30 x trituration, we have found this a 
most effective remedy, especially when the paroxysm occurs 
in the forenoon. 

Pulsatilla. — When the paroxysm comes on late in the after- 
noon, or in the evening; not well marked in all its stages; 
temperature does not mount to a great height; and there is 
little thirst. 

China. — From this remedy in potency, we have observed no 
special effect; but there are cases, especially those of recent 
origin, which seem to demand quinine in appreciable doses. 

There are many other most excellent remedies, even a list of 
which would occupy too much space for insertion in such a 
work as this. Cases which do not readily respond to the 
selected remedies, demand special search for a similimum. 

Pneumonia.— This is always a serious disease, but doubly 
so when it occurs during pregnancy. The danger here arises, 



Diseases of Pregnancy. 267 

not because of a special enfeeblement of the vital forces, or any 
peculiarity of the constitution during pregnancy ; but because 
of the extreme danger of the added complication of abortion. 
Among all the inflammations involving the parenchyma or the 
envelopes of the various organs, no one is so liable to excite 
abortion as this. Grisolle reported four cases of his own, and 
collected eleven others, out of which number four aborted a few 
days after the onset of the disease, and only one escaped 
serious symptoms. 

Pneumonia in pregnancy is unquestionably a remarkably 
fatal disease. Grisolle reports a mortality of 92.8 per cent.; 
Bican, 35.8 per cent.; Bourgeois, 7 per cent.; Wernick, 21.1 
per cent.; Chetelain, 39 per cent. Dr. George B. Peck, in 1887, 
collected the experience of nineteen physicians, which showed 
a mortality, alike for mother and child, of 14.28 per cent. 
The same statistics, however, establish the comparative infre- 
quency of the disease. 

The strong tendency to abortion is probably referable to a 
combination of causes, among the chief of which are, the 
hyperpyrexia, the intensity ot general reaction and the par- 
oxysms of cough. The cause of maternal mortality has been 
a moot point, and is not yet fully settled, but it is fairly refera- 
ble "to coexisting hydremia, and to the inability of the poorly 
nourished heart to restore the balance of a pulmonary circula- 
tion disturbed by the consolidation of lung-tissue and by the 
consequent impermeability of large capillary areas." The im- 
mediate cause of death is pulmonary oedema. 

The induction of premature labor is not to be considered in 
connection with the management of this disease, since statis- 
tics plainly show that it greatly augments the dangers. In Dr. 
Peck's tables before alluded to, we find that, out of 82 women 
who suffered miscarriage during the disease, 58 died ; while out 
of 74 who did not abort, only sixteen died. Still, if labor 
has already begun, it should be hastened as rapidly as may 
seem advisable. Under judicious homeopathic treatment we 
look for far better results than have thus far crowned old- 
school management. 

Aconite may be of some service at the very beginning, pro- 
vided it is indicated by its three prominent symptoms ; heat, 
thirst and restlessness, but not otherwise. We do not sympa- 
thize with that practice which prescribes aconite at the begin- 
ning of every acute attack of disease accompanied by fever. 



268 Pregnancy. 

Veratrum vir. may likewise afford some aid; provided the 
attack is violent, the fever high and the pulse hard and bound- 
ing. 

Bryonia. — This is the remedy from which we may expect the 
best results, even in the incipiency of the disease. Its provings 
furnish us with a better picture of the disease than any other 
in the whole list, It corresponds to the most thoroughly 
fibrinous nature of the exudation. The fever, the thirst, the 
sharp pains, worse from movement, and the cough, all consti- 
tute good indications for this remedy. 

Phosphorus.—" Experience," says Hughes, "has shown that 
it is difficult to define its sphere of usefulness, and that it may 
either come in (as Jousset recommends) to renforce bryonia 
when that medicine is not telling, or from the outset when the 
latter is not specially indicated, with the utmost advantage." 
When the exudation is being slowly absorbed, and the respira- 
tion is still accelerated, the patient complaining of a sense of 
oppression of the chest, this remedy will do good service. 

Arsenicum.— The temperature is elevated, the patient 
thirsty, restless, and sleepless. Also with a low temperature, 
and indications of sinking vitality. 

Antimonium tart. — Much rattling of phlegm on coughing 
and breathing, but much difficulty in loosening it. Especially 
serviceable during the stage of resolution. 

Among other valuable remedies are, belladonna, carbo veg., 
cuprum, lycopodium, mercurius, sanguinaria, and rhus tox. 

Phthisis.— Contrary to the commonly accepted belief, it 
appears that pregnancy, in the majority of cases, hastens the 
progress of phthisis, and precipitates its development. The 
latter is true, of course, chiefly of those women who have an 
heredity, or a strongly-acquired tendency to the disease. Out 
of twenty-seven cases collected by Grisolle, twenty -four showed 
the first symptoms of the disease during gestation ; from which, 
together with other data, we are led to believe that pregnancy 
does not exert a protective influence against the development 
of this disease. Ganlard reports thirty -two cases in which the 
condition was aggravated, and collected eighty-four in which it 
originated during pregnancy, and was evidently aggravated by 
it. In advanced stages of the disease women are not susceptible 
to impregnation. A woman with inherited tendencies to the 
disease, may escape it in a first, and possibly, second preg- 
nancy, but fall a prey to it during a subsequent gestation. 



Diseases of Pregnancy. 269 

When those suffering from this disease pass safely through 
pregnancy and parturition, their vital forces are extremely 
reduced. They supply but little milk to tbeir children, who 
are nearly always feeble, poorly-nourished, and who inherit 
consumptive tendencies. Lebart says that the influence of 
pregnancy is not only most decided, but his statistics show 
that inheritance of the disease tendency is strongly marked. 
Following are his conclusions : 

1 . Latent tuberculosis in young girls most often appears 
after marriage as the result of pregnancy. 

2. In exceptional cases the health of tuberculous women 
is not affected even by repeated pregnancies, though in some of 
these the children are feeble, and a certain proportion die early. 

3. Advanced phthisis usually prevents conception. In- 
cipient phthisis does not prevent it, and the pregnancy goes on 
to term. 

4. Abortion, pregnancy and the puerperal state determine 
the development of phthisis in at least three-fourths of the 
cases. 

5. Children born of phthisical mothers are generally feeble, 
and often develop scrofulous symptoms and then tuberculosis. 

It is fortunate for such women and their offspring that they 
have little milk, as they are thereby obliged to resort to other 
sources of nutritious supply for their children, thereby econo- 
mizing their own remaining strength, and saving their children 
from imbibing milk poorly calculated to well-nourish and to 
furnish the necessary elements for future constitutional vigor. 

Women possessing tendencies to phthisis should be dissuaded 
from entering the married state, as their interests, and those 
of society, will be best subserved by their never becoming 
mothers. 

How much good can be done for such patients is problem- 
atical, but during gestation they ought to be well fed, and 
receive arsenicum jod., phosphorus, iodium, sulphur, or other 
indicated remedies. 

Erysipelas.— Idiopathic erysipelas is much more disposed 
to attack the face than any other part, but even there is com- 
paratively infrequent in pregnancy. We have never seen a 
case, and few obstetricians have reported examples of the dis- 
ease. It would appear that pregnancy serves, not as a positive 
protection against the disease, but as measurably preventive. 
Its course is not materially altered by the woman's condition, 



270 Pregnangy. 

save in the one particular of the added complication of abor- 
tion which is prone to occur and thereby increase the gravity 
of the prognosis. The fatality is about equal to that of 
measles. 

Treatment of the disease proper is substantially that of 
cases disconnected with pregnancy. 

Belladonna stands in the front rank, being indicated by the 
cerebral fullness, throbbing headache, elevated, temperature, the 
dermatitis, etc. Heat without thirst we have always found a 
strong characteristic. 

Apis mel. — Swelling and redness of the skin ; stinging and 
burning. Little or no thirst. 

Rhus tox. — Part red and swollen, headache, dry mouth and 
much thirst, symptoms worse at night. The appearance of 
vesicles on the inflamed surface is a strong indication for this 
remedy. 

Other remedies are, arsenicum, aconite, mercurius, Pulsa- 
tilla and hepar sulphur. 

Syphilis. — With this disease in pregnancy we have had but 
little experience, and as the subject is so satisfactorily consid- 
ered by Charpentier, we quote from him as follows: "All au- 
thors agree in admitting the influence of syphilis on pregnancy, 
and of pregnancy on syphilis ; but there is a particular factor 
which imparts to this mutual influence special forms— the age of 
the syphilis. 

"1. Sometimes a woman is pregnant when she contracts 
S3 r philis, and the infection can then occur either at the begin- 
ning, during the first months after conception, or during the 
latter months. 

"2. Sometimes a woman becomes pregnant at the same 
time that she contracts syphilis. The infecting coitus has also 
been fruitful. 

"3. Pregnancy occurs in a woman who is healthy and in 
good condition, and who has never presented, nor does she 
then present, any evidence, old or recent, of syphilis, but whose 
husband has possessed, or still possesses, a syphilitic diathesis. 

"4. Pregnancy occurs in a woman affected by syphilis at 
a time more or less remote ; it was not treated, and the woman 
presents, or does not present, traces of it. 

"In the first place, w T hat are the evidences of syphilis most 
often met with in the pregnant female? According to all the 
authors who have studied the disease these are especially the 



Diseases of Pregnancy. 271 

primary and secondary manifestations. The tertiary, on the 
contrary, are rare. These manifestations are greatly influenced 
in their course, and in their character, by gestation. This in- 
fluence of pregnancy is manifested in two ways, either locally, 
or generally, and both chancres and syphilides are subject to 
the disturbing circulatory effects which exist in the pregnant 
woman, and which result in either passive or active congestion. 
According to Fournier, pregnancy complicates the pox by add- 
ing to it its own anaemia, its depressing influence, its neuralgic 
tendency, disorders of nutrition, etc. As regards the local 
manifestations, syphilis predisposes to the development of 
mucous syphilides, which assume great importance. The in- 
duration is slightly marked, being a simple hardened scale- 
parchment chancre ; but, while in the non-pregnant woman the 
duration of the chancre does not generally exceed from four to 
^ve weeks (rarely more, often less), in the pregnant female the 
mean duration of the chancre is about two months and twenty 
days. 

"According to Fournier, mucous papules are not only very 
common, but they develop in pregnant women a remarkable 
exuberance, assume rapidly the budding, vegetating, or hyper- 
trophic variety, and often form actual tumors, which invade and 
distort the entire vulva. Moreover, they are always more 
rebellious than usual, and disappear more slowly. Syphilitic 
ulcers are quite frequent in pregnant women ; they are livid, of 
a violet color, excavated, and are rendered still deeper by the 
vascular turgescence of the parts. They usually persist for a 
longer or shorter period, and often tend to progress. It is 
sometimes extremely difficult to cause them to cicatrize before 
delivery. While the duration of syphilides, in the non-pregnant 
state, varies from two to two-and-a-half months, it varies from 
three to three-and-a-half during pregnancy. Guerin , who agrees 
with Fournier on this point, affirms that during pregnancy the 
mucous patches increase in number, and grow in spite of general 
and local treatment as long as the pregnancy continues; or 
that if they disappear for a short time, they have a great 
tendency to return, not only on the genitals, but also on the 
fauces, tongue, and lips. Their persistence, according to him, 
proves that treatment is not so effective as it is in the non- 
pregnant condition. 

" The Influence of Syphilis on Pregnancy.— Although the 
influence of syphilis on pregnancy is unquestioned, it is, how- 



272 Pregnancy. 

ever, not absolute, and varies with the conditions according to 
which syphilis appears in women. The important feature is the 
frequency of abortion and premature delivery. Among 657 
syphilitic females, 231 miscarried, while 426 were delivered at 
term of living and dead children. But as we have seen, four 
cases may be presented, and we must consider here: 

" The father alone is syphilitic. The mother has never pre- 
sented, nor does she now present, any manifestations of syphilis. 
The idea of direct transmission from the father to the foetus, 
without participation on the part of the mother, which was 
opposed for some time, has been defended by Trousseau, Diday, 
Bourgeois and many others. It remains to-day incontestable, 
and we have observed numerous cases. 

" As regards maternal syphilis, we have seen that (1) the 
woman may be affected before conception; (2) syphilis and 
pregnancy may begin simultaneously; (3) syphilis may have 
been contracted after conception, at a period of pregnancy 
more or less advanced. 

" 1 . Syphilis existing Before Conception.— A syphilitic woman 
who becomes pregnant is far more predisposed to abortion than 
a pregnant woman who subsequently becomes syphilitic. This 
is especially observed in cases of repeated abortion, and it is 
now a classical fact that all accoucheurs, both in France and 
abroad, with a few exceptions (happily rare), advise that, when 
successive abortions are observed in the same woman without 
apparent cause, she should be put on antisyphilitic treatment, 
and that, too, not only when no specific manifestation is present, 
but even when she has not shown any. 

" When the pregnancy advances to term, (1) thechild maybe 
born healthy and in good condition, and remain so (this is 
exceptional) ; (2) It may be healthy when born, but may, 
during the first three months after birth, rarely later, show 
symptoms of syphilis (quite frequent) ; (3) It may show 
symptoms of syphilis from its birth, and may then either 
succumb quickly (the rule), or may be cured by appropriate 
treatment (the exception) ; (4) Although apparently healthy 
when born, it may die within a few days, either by reason of its 
feeble condition in consequence of premature delivery (often), 
or from convulsions (when delivered at term). 

"2. Syphilis and Conception are Concomitant. — Here, too, 
abortion is the rule, or at least delivery is often premature, and 
in consequence of the rigid treatment to which the mother is 



Diseases of Pregnancy. 273 

subjected, the child may, in exceptional cases, be born healthy 
(or without evident traces of syphilis), and then, as in the 
former instance, may either be cured or may succumb. 

"3. Svphilis is Contracted After the Fourth or Fifth Month 
of Pregnancy, — In this case the danger is less. Abortion does 
not take place, but delivery is often premature, and when the 
foetus reaches full term it may frequently be born healthy ; or it 
may be apparently healthy when born, but may present syphi- 
litic symptoms within two or three months after birth. 

"4. Finally, the Woman Contracts Syphilis Only at the 
Termination of Pregnancy.— -Then the danger is almost nil; 
pregnancy is concluded in the ordinary manner at term by the 
birth of a living, healthy child. It is during the secondary 
stage, that is, from the fourth month to the second year of this 
period, that maternal syphilis seems to predispose to abortion. 
But. as we know, syphilis may be active at the end of three, 
four, five, six years, or even longer. Those women are most prone 
to abort who are affected with severe forms of the disease — those 
who, to use Fournier's expression, are affected -rudementetvis- 
ceralement:' but abortion may occur in all forms of the disease, 
even the lightest, and is often the sole expression of the diath- 
esis. 'There are a certain number of women,' says Fournier, 
'who abort exclusively because of syphilis, without, at the 
same time, presenting, or having presented, for a period more 
or less remote, any appreciable specific symptoms.' In his 
opinion, then, even latent syphilis is still capable of causing 
abortion. We share this conviction fully. 

"We see, therefore, that syphilis is one of the diseases that 
deserves the greatest attention on the part of the accoucheur, 
and we realize the full importance of treatment in the interest 
of the mother as well as the child. Some writers have neverthe- 
less insisted that these ravages should be attributed, not to the 
pox, but to its antidote, mercury. Such a view could not be too 
strongly opposed, and all obstetricians agree with the syphilo- 
graphers in advising mercurial treatment during pregnancy, 
not only in the case of women who are actually affected by 
syphilis, or who show evidences of it. but in every instance in 
which the father has had syphilis, and where there have been 
repeated abortions without any known cause." 

We are not quite sure that many of the aggravated 
symptoms sometimes seen in the subjects of syphilis under old- 
school treatment, do not owe the aggravation, at least in part, 
(18) 



274 Pregnancy. 

to the character of the treatment which they have received. 
At any rate, such cases are not with us so numerous. 

Treatment. — That which follows was prepared by T. S. 
Hoyne, M.D., at our request, especially for this work. 

In the treatment of primary syphilis, mercurius cor. holds 
the first place, if mercury has not already been taken without 
benefit. A decided improvement should follow the adminis- 
tration of this drug within four or five days, especially if the 
ulcer is superficial, with free secretion of thick pus, or in case 
the ulcer is spreading and penetrating at the same time. 

Mercurius jod. flav. follows well if the former preparation 
does not alter the ulcer for the better. 

Cinnabar acts well in scrofulous patients. 

Nitric acid always proves useful in persons who have taken 
considerable mercury without benefit. The special indications 
are, easily-bleeding chancres ; superficial or elevated ulcer with 
zigzag edges, where no signs of central granulation are present. 

Arsenicum is a very important remedy, and one not to be 
overlooked when the chancre becomes gangrenous or phage- 
denic ; also for ulcers w 7 ith proud flesh and bleeding edges ; and 
for ulcers with a copious, thin, foetid discharge. 

In secondary syphilis the remedies which have proved bene- 
ficial may be grouped as follows : 

Ars., phos., carbo veg., calc. carb., hepar sulph., silicea, 
sulphur and kali carb. — Falling out of the hair. 

Calc. carb., iodium, petroleum, silicea, phosphorus and sul- 
phur. — Cervical adenitis. 

Nitric acid, thuja, arg. nit., calc. carb., lachesis and arsen- 
icum. — Ulcers in the mouth and throat. 

Nit. ac, arsenicum, calc. carb., mercurius, phosphorus, 
lycopodium and sulphur. — Erethema and roseola. 

Arsenicum, nit. ac, aurum, ars. jod., coral, mercurius, hep. 
sulph., phosphorus and phos. acid. — Squamous and scaly 
diseases. 

Hepar sulph., tellurium, silicea, sulphur, nit. ac, lachesis, 
ant. tart., graphites and mercurius.— Pustular diseases. 

In the tertiary form of the disease aurum is indicated for the 
affections of the, bones of the skull with a suicidal tendency. 

Phos. acid. — Low r -spiritedness, with intense pain iu the peri- 
osteum of the bones. 

Silicea and kali jod. in scrofulous persons, with ulcerations 
of the bones and fistulous opening. 



Diseases op Pregnancy. 275 

Asaf&tida. — Cramping, jerking and drawing in the bones at 
night : nodes very sensitive to the touch. 

Fluoric acid. — Burning and intermittent pain in the bones. 

Nitric acid for exostoses in patients who have taken large 
quantities of mercury. 

Rhus tox — Rheumatic pains aggravated on first moving 
after rest, and on getting up in the morning; paralysis of lower 
limbs. 

Carbo veg\— Lung complications, with loose rattling cough. 

Arsenicum. — Psoriasis palmaris and plantaris. 

Benzoic acid. — Intestinal complications, with copious, watery, 
foetid diarrhoea. 

St aphis agria— Caries of the teeth ; ostitis and periostitis. 

Goitre.— Primary development during pregnancy is quite 
rare; but increase of antecedent goitre, both in size and an- 
noyance, is frequently noted. 

Iodine is doubtless the best remedy for goitre, though other 
remedies have cured many cases. We regard the galvanic cur- 
rent of electricity as very effective. 

Uterine Rheumatism.— We quote again from Charpentier: 
"Cazeaux and Gauthier have particularly called attention to 
this disease. Cazeaux considers it true rheumatism, but 
Gauthier regards it as identical with uterine neuralgia, which 
may also occur aside from pregnancy. Gestation produces 
modifications, however, in its course. Spiegelberg and Braun 
do not believe in uterine rheumatism and consider it as a result 
of either endometritis or metritis. 

"Symptoms. — Among twenty-nine cases collected by Gau- 
thier, eighteen commenced during pregnancy., before labor, and 
eleven began during parturition. The attack is never sudden. 
Before the appearance of uterine pain the patient complains of 
pains and contractions in the limbs and the trunk, of vertigo, 
palpitations and of syncope. Shortly afterwards, or at the 
same time, a continuous, dull pain, of variable intensity is felt 
in the sacrum the hypogastrium and the lateral abdominal re- 
gions. This pain is exaggerated by movements of the mother 
or of the foetus. At the end of a few hours or days, the pain 
becomes suddenly violent, sharp, lancinating, and lasts from a 
few seconds to several hours, beginning at the uterus, radiating 
into the lower limbs, and extending to the bladder and rectum. 
On applying the hand to the abdomen, we find that its walls are 
not the seat, and that the pain is uterine and not so limited as 



276 Pregnancy. 

in ordinary neuralgias. Almost always one of the surfaces or 
sides of the uterus is the chief seat of the pain. The pain is 
generally fixed, but ma} 7 be mobile, the fundus uteri being 
usually less affected than other regions. The women experience 
a sensation of spasmodic constriction, due to uterine contrac- 
tion, perceived by both patients and obstetrician during the 
earlier months. The uterus, in fact, grows hard. Sometimes 
it is smooth and sometimes nodular, from partial contractions. 
When the organ is large we can appreciate these changes in 
form, which may, in certain cases, produce an annular trans- 
verse constriction. The latter may be partial, and involve 
different parts of the uterus, including the cervix, and may oc- 
casion, according to the case, either rigidity, or rapid dilatation 
of the cervix. 

"Gauthier admits two forms, one acute, febrile, and one 
chronic, apyretic form. The former may succeed the latter or 
may present momentary acute exacerbations. Uterine rheu- 
matism occurs most frequently at term and during labor, at 
which time it may become the cause of dystocia. It may be 
developed after labor, either immediately or after a few hours. 
It then causes spasmodic uterine contractions, which lead to 
retention of the placenta. Finally, it may occur later yet, 
after fifteen days, as in a case of Neucourt. 

" The usual complications are neuralgic or rheumatic pains 
in certain vescera, in the muscles or in different nerves, particu- 
larly the vesical and rectal nerves. Luroth has seen a case of 
rheumatic meningitis, and finally, there may be muscular pains 
in the face, the neck, the arm, the shoulder, the thoracic walls 
and the lower limbs. 

"Very prone to relapse, this affection may recur several 
times, during or after pregnancy. The intervals vary from two 
or three days to several weeks. An individual attack varies 
from a quarter of an hour to twelve days, at the longest, but 
in general it does not exceed twenty-four or forty-eight hours. 
The disease may reappear in successive pregnancies. It may 
end in recovery, which is the rule; in a chronic condition, in 
metritis and in eclampsia. 

"1. Influence upon Pregnancy. — When the attacks have 
lasted a certain time, and have been violent, they are followed 
by uterine contractions, and may thus provoke labor. But it 
is not always so, and Wigand quotes a case where the cervix 
dilated, and the bag of waters formed; when everything was 



Diseases of Pregnancy. 



277 



arrested, labor ceased, the os closed, the cervix regained its 
former length, and pregnancy went on its course. Sometimes 
the pains simulate labor without inducing it, and they may 
occasion faulty presentations. 

'•'2. Influence upon Labor. — Uterine rheumatism impedes 
labor, and sometimes even renders the spontaneous expulsion 
of the foetus impossible by interfering with the pains, by pro- 
ducing spasm of the cervix, and by preventing the woman from 
making voluntary expulsive movements. 

"3. Influence upon the Puerperal Functions.— By causing 
tetanic uterine contractions it may produce dystocia, or may 
occasion hemorrhage by inducing uterine atony, which may be 
followed by metritis or by perimetritis. 

" Causes.— These are difficult of detection. The disease may 
appear under all circumstances and at any stage of pregnancy. 
Gauthier saw it begin in twenty -nine cases, as follows : 



In the second month, 1"| 



" third 
" fourth 
" fifth 


3 

1 
1 


" sixth 
" seventh ' 
" eighth 
" ninth 


' 2} 

' 4 
5 

< 12 



In the first five months, 6 times. 



In the last four months (twelve occurring in 
the last month), 23 times. 



"Meissner regards rheumatism as a neurosis of uterine sen- 
sibility and motility, caused by peripheral irritation, and 
particularly by cold. 

" The predisposition increases as the full term approaches, and 
is notably augmented near the time of labor. 

"Prognosis .— Although not fatal to the woman, uterine 
rheumatism is still serious because it may occasion abortion or 
premature labor, or by retarding and complicating labor it 
makes the condition of both mother and child much less favor- 
able. It is particularly disagreeable when developed at the end 
of pregnancy, because of its tendency to recur several times 
before confinement, even when it does not interrupt pregnancy. 
In these cases it almost always recurs during parturition, which 
it renders long and difficult. " 

Treatment.— The homeopathic medication of rheumatism 



278 Pregnancy. 

is not as satisfactory as we might wish, and yet by means of it 
we are frequently enabled to make some brilliant cures. 

Caulophyllum. — This we regard as one of the very best rem- 
edies for the treatment of rheumatic conditions during preg- 
nancy, and it is probable that, on account of its virtues in this 
direction, it has acquired a reputation for producing painless 
labor. Many of the false labor-pains which precede the true, 
and cause so much annoyance, are due to a rheumatic condi- 
tion of the uterus, and caulophyllum, when systematically 
administered for a few weeks prior to labor, removes this, and 
leaves nothing but the labor-pains pure and simple to be suf- 
fered. Its control over after-pains, in certain cases, is probably 
due to a similar action. It is a remedy which we always use in 
the fluid extract. 

Arnica is often serviceable, especially when the muscles feel 
lame and sore as if they had been bruised. 

Bryonia is indicated by its usual characteristics of aggrava- 
tion on motion, sharp, tearing, drawing pains, usually worse in 
the morning and from touch. 

Ehustox. — Soreness and stiffness of affected parts; worse 
during rest ; during cold, damp weather, and at night. 

These are the leading remedies, but other valuable ones are : 
cimicifuga, colchicum, mercurius, Pulsatilla, ranunculus, rhodo- 
dendron and sulphur. 

Women suffering from uterine rheumatism ought to be 
placed under the influence of an anesthetic as early in labor as 
their safety will justify, and the delivery hastened as rapidly as 
the conditions will allow. 

Insanity of Pregnancy.— During the latter part of 1888, 
and the early part of 1889, Dr. H. H. Crippen published an 
article in sections, in The Homeopathic Journal of Obstetrics, 
under the above caption, so complete in detail, and so excellent 
in character generally, that for this entire account of the 
Insanity of Pregnancy, I have drawn almost wholly from the 
article named. 

"More than two years ago," says Dr. Crippen, "in writing 
on this subject, I stated that, 'in selecting the title Insanity of 
Pregnancy for this paper, I have been guided by two reasons: 
first, that I might include all conditions pertaining to the 
mental aberrations arising from any of the exaggerated physi- 
ological influences affecting the child-bearing woman; and 



Diseases of Pregnancy. 279 

second, that the term puerperal mania, usually made to include 
all these conditions, is a misleading one, as many cases belong 
to the class of melancholia as to mania.' To-day I find myself 
supported in this view by Charpentier, who includes in the dis- 
eases of pregnancy, the insanity of pregnant women, insanity 
developed during labor, during the puerperium, and during 
lactation, and further says : ' True puerperal mania, we admit, 
will manifest itself three or four weeks after labor, but it seems 
impossible for us to separate it entirely from the insanity of 
the pregnant or of nursing women. We therefore include 
these forms in our study.' From conception to the end of 
lactation we have a period marked by a series of physio- 
logical crises, and insanity, therefore, whether associated with 
the pregnant state, with parturition, or with lactation, is 
merely consequent upon a sequence of events that arise from 
pregnancy directly, or have that condition as their antece- 
dent." 

Before discussing symptoms, we will rapidly review the 
statistics. 

"1. The Proportion of Insane Patients Occurring Among 
Pregnant, Parturient, or Nursing Women. — The statistics are 
not only hard to obtain, but are also very untrustworthy, 
chiefly on account of nomenclature." Crippen then gives the 
following table : 

Charpentier's statistics Among 6,700 found 41 cases. 

Columbia Hospital " 1,149 " 3 " 

Freedmen's Hospital " 680 " " 

8,529 44 

That is .529 per cent., or 5.29 cases out of every thousand. 
Even allowing that this is a higher estimate than the percent- 
age of cases occurring in private practice, there is still a great 
discrepancy between this and Fernald's statement that, at the 
lowest estimate, at least one out of every thousand lying-in 
women becomes insane. 

" 2. The Extent to which Insanity is Due to Causes Relating 
to Pregnancy .—During the winter I spent at the Bethlehem 
Royal Hospital, I found that out of 561 female patients, there 
were 58 cases, or 10.3 per cent." According to other sta- 
tistics which follow, the percentage is raised to 7.83. 



280 Pregnancy. 

3. Kelative frequency of the cases during pregnancy, during 
the puerperium, and during lactation : 

Number of cases. Pregnancy. Puerperium. Lactation. 

Palmer 19 2 6 12 

Esquirol ,. 92 54 38 

Han well (Connolly) 43 4 26 13 

Macdonald 66 4 44 18 

Marce 310 27 180 103 

Tuke 155 28 73 54 

Leidesdorff 20 6 14 

Crippen 58 7 47 4 

Total 763 78 444 242 

"1. Insanity During the Period of Pregnancy. — Besides the 
physical disturbances caused by changes taking place in the 
constantly increasing bulk of the uterus, we are all familiar 
with the various modifications in the tastes, habits, and tem- 
perament of a pregnant woman. To what degree such changes 
belong to the ' borderland of insanity ' (so happily treated of 
by Maudsley), it is difficult to say. A slight derangement of 
the physical processes may produce eccentric longings, affect 
the emotions, the intellect, or the will, or change the habit of 
life, so that those who were energetic may become indolent and 
lazy, while others may become irritable, with a tendency to the 
perpetration of unusual acts. Besides the perverted longings 
and hysterical affections, the unstable conditions may amount 
to moral perversions, such as dypsomania or kleptomania, 
which in some cases may be gradually developed, and in others 
suddenly and irresistibly implanted. The proportion of cases 
of insanity occurring during pregnancy has already been shown 
to be comparatively small, being not nearly as common as 
those at or following childbirth. In my list of 58 cases, the 
seven that occurred during the period were all found to have 
their origin during the latter months. In the earlier months 
excessive vomiting produces great exhaustion, and to this 
physical weakness, combined with a neurotic tendency, or to 
the latter alone, may be due those extraordinary longings and 
nervous symptoms, that, passing beyond the limits usually 
met with, become insanity. This may pass off to reappear 
after delivery, or may continue in an unbroken course through 
pregnancy to parturition, or beyond it, but the majority of 
cases ultimately recover. 

"2. The Period Beginning with Labor and Ending with the 



Diseases of Pregnancy. 281 

Lochial Discharge.— Physiologically the pains of labor may 
often start considerable mental disturbance, and from this 
instability it is that cases of this period are more numerous 
than those of the two other periods combined. In my expe- 
rience, nearly seventy per cent, of the cases of insanity of 
pregnane}^ appear during this time. This is the period in which 
the term puerperal insanity may be applied to the mental un- 
soundness. With this group I have included miscarriage, of 
which I have the histories of seven cases. They differ but little 
from those of labor at full term, except, perhaps, in the partic- 
ular that complications exist, such as severe flooding, or that 
there might have been a shock as a causation of the premature 
delivery and likewise of the weak-mindedness. 

"The type of insanity varies much. In my own experience 
melancholia and acute mania predominate, the former slightly 
in excess." 

"Those cases of emotional, morbid, objective impulses, 
marked by homicidal and suicidal propensities, are of more 
interest in a medico-legal point of view. They are usually as- 
sociated with aversion to the children or to the husband, or, on 
the other hand, the impulse to destroy life may be the result of 
a delusion. That such cases are common are recognized by all. 
An analysis of my list of cases shows that sixteen were suicidal, 
nine homicidal. The refusal of food is a serious consideration, 
and cases are constantly coming to the hospital in an ex- 
hausted condition from the lack of sufficient means of forced 
feeding at home. 

" Some cases are apathetic from the beginning ; take no no- 
tice of husband or child ; have a dull vacant look ; are dirty in 
their habits and tend to lapse into indifference to their sur- 
roundings ; so that, unless we succeed in arousing their torpid 
mind, they pass into a condition of dementia. 

"As to temperature. Dr. Campbell Clark, of Edinburgh, 
draws attention to four types of temperature curves observed 
among twenty cases: (a) 'A moderate and uniform increase 
in uncomplicated cases.' (b) 'A periodicity of increase and 
decrease.' (c) 'A uniformly high evening temperature with 
well morning remission in phthisical cases.' (d) 'A persistent 
high temperature pursuing an erratic course.' His comment on 
these differences in temperature curves is worthy of note. A 
significant addendum to the above statement is that cases of 
the (c) and (d) types died. 



282 Pregnancy. 

"3. Insanity Due to Lactation. — This condition is usually 
associated with exhaustion after prolonged nursing, or it may 
appear in a weakly woman unable to stand this extra tax 
upon her strength after having passed through the puerperal 
state. So that the term over-lactation is relative, depending 
purely upon the accompanying conditions. 

"In these conditions the physical exhaustion leads to men- 
tal depression. To the exhaustion are due the anaemic appear- 
ance, the shortness of breath and the sleeplessness ; while the 
uneasy feelings the patient experiences lead to delusions and 
hallucinations of sight, hearing or smell. Naturally enough 
the depressed state of the mind tends to delusions of unworthi- 
ness, so that the usual condition is that of melancholia. 

"Etiology. — Primarily we may look upon the mental aber- 
ration as dependent upon an overthrow of that unstable 
condition of mind which arises from causes associated with or 
following pregnancy, but there are many important secondary 
considerations to be referred to in this relation, since the disease 
presents, in so many cases, a double, a triple, or even multiple 
combination of causes. We may look upon the causes as pre- 
disposing and exciting, or again as moral, social, and physical ; 
but rather than confuse by attempting any dividing line, it is 
preferable to consider each one separately. 

" Heredity. — The influence of heredity in predisposing to 
insanity is becoming well recognized. In consequence of a 
sameness of conditions of long duration in the past, tissues 
may receive modifications that produce a proneness to suffer in 
a particular manner when exposed to ordinary exciting causes. 
In the instances which we are considering, the nervous system 
has been especially influenced in the particular direction to be 
pointed out under the discussion of pathology. 

"In my experience, twenty-three out of fifty-eight cases had 
a family history of insanity ; in eight cases the mother had 
suffered from insanity, and in one case there was the remark- 
able history of da.ughter, mother and grandmother, all having 
puerperal mania. In seven cases phthisis existed in the family, 
and in three there was a history of cancer. 

" Closely associated with heredity, as a predisposing cause, is 
the history of previous neuroses in the patient. In the histories 
of thirty-six out of fifty-eight cases, there existed previous 
nervous disorders varying from convulsion to derangements 
of the mind. These cases include fourteen having previous 



Diseases of Pregnancy. 283 

attacks of insanity during pregnancy, during the puerperium 
or during lactation, of which eleven were second and three 
third attacks. 

"Number of Pregnancies.— Most authorities affirm that 
primiparae are most subject to the disease. In my own experi- 
ence the proportion of primiparae to multiparas was twenty-six 
to thirty -two. The special point to be emphasized is that cases 
having children rapidly are liable to suffer from exhaustion. 

"Age. — The following table will show at a glance the pro- 
portion occurring at different ages : 

Number From 15 to From 20 to From 25 to From 30 to From 35 to Over 40 

of cases 20 years 25 years 30 years 35 years 40 years years 

Observer, reported, of age. of age. of age. of age. of age. of age. 

Clouston. ..60 3 16 29 9 12 

Mare6 55 1 13 17 13 5 6 

Savage ....207 49 67 44 29 18 

Crippen.... 58 1 16 17 12 9 3 

380 5 94 111 78 55 27 

"From this table it would appear that those in the earlier 
periods suffer most from this condition, but, since at this time 
fecundity is greater and the proportion of births greater, I 
believe that the tendency to insanity increases with age; for, 
with increasing age, we find women less able to bear the trials, 
worry and exhaustion of pregnancy, parturition and lacta- 
tion. 

"Qualitative Changes in the Blood.— A perverted condition 
of the blood quickly exercises a marked effect upon the function 
of the cerebral cells, and while I believe that the quantitative 
change in the blood-supply to the brain is most often the 
pathological condition, yet there certainly are cases of insanity 
of the variety under discussion that are due to a physical 
deterioration of the blood. Thus, in consequence of defective 
nutrition in the exhaustion produced by lactation, or by ill 
conditions of existence — as overcrowding, bad air, insufficiency 
of food, intemperance— we may find both predisposing and 
exciting causes." 

Dr. Crippen mentions Sir J. Y. Simpson's claim that albu- 
minuria is a prominent factor in the production of insanity of 
the sort under consideration, and adds that "though this 
extreme view of Sir J. Y. Simpson has not met with general 
acceptance, it must not be put aside, and I have intentionally 
dwelt upon it with the idea of emphasizing the fact that 



284 Pregnancy. 

frequent analyses should be made of the urine of pregnant 
women." 

"There still remains for discussion a multitude of minor 
causes both predisposing and exciting. Miscarriage, that may 
or may not be followed by hemorrhage and exhaustion, is the 
cause of a considerable number of cases. Exhaustion may be 
dependent on excessive vomiting in the early months of preg- 
nancy, upon prolonged labor, upon severe hemorrhage at 
parturition, or may be dependent on over-lactation. The use 
of chloroform has been blamed as an exciting cause, but I have 
no history of such a case. It is also possible that forceps have 
a share in the causation, but as such there are very few cases 
on record. 

"The French claim that mothers of illegitimate children are 
very liable to puerperal insanity. 

"Pregnancy especially, of all these periods, renders women 
more sensitive, nervous, erethistic, and excitable. At such a 
time an unkind word or look, indifference, or even thought- 
less neglect on the part of the husband, weighs with a heavy 
burden upon an already unstable mind. In the case of melan- 
cholia, the weight of sorrow presses energy and will out of 
place, and the whole intellectual life revolves around one 
painful fixed spot. Anxiety, with the dread and peril of labor, 
may produce a self-consciousness, passing into a morbid state. 
So varied are the causes that one hardly knows where to draw 
the line, and to add to the difficulty, it is rare to find causes 
acting singly; more often they are multiple. 

"Diagnosis. — It is unnecessary to speak of the diagnosis of 
the insanity of pregnancy or of childbed, except that it is 
essential to differentiate acute puerperal mania from the so- 
called puerperal phrenitis and from the delirium of puerperal 
fever. 

"We distinguish puerperal meningitis as a distinct disorder, 
that may be differentiated from acute mania by the contracted 
pupils, the intense headache, the high temperature, and the 
rapid progress of the disease towards collapse. On the contrary , 
in acute puerperal mania, the pupils are usually dilated, the 
headache is not a prominent symptom, and the temperature 
seldom reaches a high degree except Avhen complications are 
present. The premonitory symptoms of acute mania are also 
distinctive, and have existed for a longer time preceding the 
marked onset of the disease. Some singular change of manner 



Diseases of Pregnancy. 285 

or mode of thought, or querulousness with incoherent talking, 
commonly appears before the violence of the attack. 

" Prognosis.— It appears to me that before so much attention 
was paid to puerperal fever and to puerperal septicaemia, many 
cases of puerperal mania must have had these conditions as com- 
plications. Certain it is that the death-rate was greater than 
it is at the present day. Under Esquirol, in La Salpetriere, out 
of ninety-two cases, six died, or one in fifteen. Of Dr. Burrows' 
fifty-seven cases, ten died, or one in six. Of Leidesdorff s twenty 
cases, one died. Webster saw five deaths in one hundred and eleven 
cases. Among fifty-eight cases in my own experience, one died. 

' ' Besides prognosis as to life, we have the question of recovery 
of the mental faculties. Generally it is believed that the ter- 
mination is favorable, and this is borne out by statistics. Dr. 
AVebster states as the result of his observation that ' three in 
every five cases of puerperal insanity may be confidently ex- 
pected to recover within a year.' Two-thirds of Esquirol's 
cases were cured within the first six months after the com- 
mencement of the attack. Of Dr. Palmer's nineteen cases, 
fourteen had recovered after four months' treatment, and two 
w r ere convalescent. Of the thirty-five cases recovering under 
Dr. Burrows' observation, nine recovered in the first month, 
five recovered in the second month, five in the third, three in 
the fourth, two in the fifth, four in the sixth, one in the seventh, 
two in the eighth, one in the ninth, one in the fourteenth, and 
one in the twenty-fourth month. Dr. Burrows continuing, says 
that one recovered after three years, two after four years, one 
after six years, and one after seven years, and that he never 
met with one permanently fatuous from insanity. 

'• In making up one's prognosis it is well to bear in mind the 
brief aphorism of Gooch, which still holds good after more 
than half a century has elapsed. Briefly stated this is, that 
acute mania is a less durable disease than melancholia; it is 
more dangerous to life, but less dangerous to reason. 

"It remains but to say that insanity may follow upon puer- 
peral fever as after any other acute exhausting disease, and 
that the termination depends much upon the condition of de- 
bility. Suicidal tendency, too, is dangerous to life, more 
especially where morbid impulses exist, than where there are 
delusions prompting the patient to destroy her life. To some, 
then, the prognosis with regard to life depends on complica- 
tions, and if death occurs it is more often from secondary causes. 



286 Pregnancy. 

"In all forms of insanity there exists a tendency to future 
attacks after recovery, and we have this well marked in the 
conditions under consideration. This tendency must be given 
due weight in prognosis, and especially must it receive careful 
thought if there is a family history of neuropathies. But a 
previous attack does not necessarily imply that the next preg- 
nancy will be followed by an upset of the mental balance; cases 
are cited in which the first attack was before marriage and the 
next not until after the eighth child, and again, where patients 
have suffered after the first and third, third and fifth, or fourth 
and sixth pregnancy." 

Treatment. — Passing by general considerations with re- 
spect to the question of removal to an asylum, the sanitary 
surroundings, the quality and quantity of food, as well as the 
methods of administration, we shall here give only the medi- 
cinal treatment, which is set forth by Dr. Crippen in a most 
perspicuous manner. 

" Aconitum. — Melancholia following excitation produced by 
fear. The morbid state of the mind approaches dementia in 
lack of courage, confidence, and energy of character. Moans 
and lamentations arising from the apprehension that her death 
is near. She becomes positive of the date of her death. Weak- 
ness of memory ; loses the faculty of remembering dates. Ex- 
pression of terror and imbecility in the countenance. 

"In mania accompanied with febrile condition. Fitful mood ; 
at times in furious delirium, again in full possession of the 
mental faculties. Delirium, especially at night. 

" Act sea racemosa. —Melancholia following labor. A heavy 
cloud of misery hangs over the patient. Dr. E. M. Hale places 
great stress on the symptom of sleeplessness as a key-note, 
and gives also as characteristic symptoms : ' She was suspi- 
cious of everything and everybody ; would not take medicine if 
she knew it ; indifferent, taciturn ; takes no interest in house- 
hold matters; frequently sighs and ejaculates; great appre- 
hensiveness and sleeplessness. 

" Aurum. — Suicidal mania with dejected spirits. Religious 
mania; she howls and screams and imagines she is irretrieva- 
bly lost because she has neglected some duty. Aurum is 
seldom indicated in the melancholia of females. Platina will 
more often be found suitable in such conditions, arising from 
disturbances of the sexual organs of the female. 

"Belladonna. — The w T onderful effect of this drug over dis- 



Diseases of Pregnancy. 287 

eases of women extends equally to the mental symptoms 
arising from disturbances of the female genitalia. In its patho- 
genesis we find: foolish manner; immoderate laughter; she 
sings merry but senseless songs; mania; she spits at those 
around her; bites, strikes and tries to escape and hide herself; 
delirium, which returns in paroxysms, first of a merry nature, 
afterwards changing to rage. 

"Bromide of Potassium. — Dr. E. M. Hale gives the follow- 
ing : ' Puerperal mania, when attended by ferocious or erotic 
delirium. He advises its use in minute doses 3 X to 6 X ,in mental 
depression from cerebral anaemia or exhaustion. The patho- 
genesis of kali bromatum is suggestive of dementia. 

" Chamomilla.— Mental erethism. Angry and out of humor; 
cannot bear to be spoken to or interrupted. Slight irritations 
of the mind produce great anguish and distress. Inclined to 
be quarrelsome ; she seeks a cause for quarrelling. Irritability, 
even amounting to incivility. 

" China. — Mania following hemorrhage or after prolonged 
lactation. Excessive sensitiveness of the whole nervous sys- 
tem, debility, exhaustion, intolerance of noise; extreme anx- 
iety and apprehensiveness. The patient sees persons and 
objects on closing the eyes ; these disappear as soon as the eyes 
are opened {calc. ost., bell). 

" Cuprum aceticum.— Cuprum metallicum appears to have 
been a reliable remedy in mania in Dr. Jahr's experience, but I 
place greater confidence in the acetate, in the following condition : 
Mania appearing in paroxysms; confused look; at times she 
is in apparent full possession of her mental faculties, yet is liable 
to paroxysms of howling, which come suddenly and unexpectedly. 

" Hyoscyamus niger— This remedy seems especially adapted 
to acute mania in which there is excitation without any evi- 
dence of inflammation. The symptoms as given by Farring- 
ton will apply equally well for our purpose. ' The patient under 
such circumstances has many flexible notions, all arising from 
these morbid impulses. He imagines, for instance, that he is 
about to be poisoned. Possibly he will refuse your medicine, 
declaring in angry tones that it will poison him. Or he imagines 
that he is pursued by some demon, or that somebody is trying 
to take his life. This makes him exceedingly restless. He 
springs out of bed to get away from his imagined foe. The 
senses, too, are disturbed. Objects look too large, or else are 
of a blood-red color. Sometimes objects appear as if they were 



288 Pregnancy. 

too distinct; that is, they have an unnatural sharpness of 
outline. The patient talks of subjects connected with everyday 
life, jumping from one subject to another pretty much as in 
lachesis; all this time the face is not remarkably red, possibly 
it is only slightly flushed. The pupils are easily dilated; sleep 
is greatly disturbed ; the patient lies awake for hours. 

" 'At other times we find thedelirium returning anew and the 
symptoms take another form. The patients are silly and laugh 
in a flippant manner. Sometimes, for hours at a time, they will 
ha/ve a silly, idiotic expression on the face. Again, they become 
lascivious, throw the covers off and attempt to uncover the 
genitals. The abnormal movements accompanying these symp- 
toms are rather angular ; they are not at all of the gyratory 
character of stramonium.' 

" Ignatia. — Melancholia; despairs of her salvation; imagines 
she has been faithless to her husband ; weeping bitterly ; tense- 
ness of the abdomen ; cold hands and feet ; desires to be alone 
with her grief. 

u Lilium tigrinum. — In comparison with sepia Dr. S. H. 
Talcott gives the following indications : ' Lilium and sepia find 
an important place in the treatment of depressed and irritable 
women. The troubles in such cases originate largely in the mal- 
performance of duty on the part of the generative organs. 
Bobh lilium and sepia cases are full of apprehensions and 
manifest much anxiety for their own welfare. In the sepia cases, 
how T ever, there are likely to be found more striking and serious 
organic changes of the uterine organs; while the lilium case 
presents either functional disturbance or a very recent and 
comparatively superficial organic lesion. Lilium is more 
applicable to acute cases of melancholia where the uterus or 
ovaries are involved in moderate or subacute inflammation, 
and where the patient apprehends the presence of a fatal 
disease which does not in reality exist. The lilium patient is 
sensitive, hyperesthetical, tending often to hysteria. She quite 
readily and speedily recovers, much to her own surprise, as well 
as that of her friends, w T ho have been made to feel by the patient 
that her case was hopeless. The sepia patient is sad, despairing, 
sometimes suicidal, and greatly averse to work or exercise. 
There is, however, often a good reason for the patient's 
depression, for, too frequently, she is the victim of profound 
organic lesions which can, at best, be cured onlj by long, 
patient, and persevering endeavor.' 



Diseases of Pregnancy. 289 

" Opium.— Furious mania, with distortion of the features, 
bloating and redness of the face, bluish reduess and swelling of 
the lips. Exalted imagination; frightful visions of ghosts, 
demons and horrid beasts. 

"Platina. — Very proud and haughty. Excitation of the 
sexual passions, with voluptuous crawlings and tinglings in the 
genitals, nymphomania. Melancholia; thinks she is not fit for 
the world, is tired of life, but has a dread of death. The feeling 
of great personal superiority is the manifest characteristic of 
this remedy. Persons are looked down upon as inferior and 
insignificant. She is out of sorts with the world, for everything 
seems too narrow. Objects about her look to be smaller than 
natural. 

"Pulsatilla— Depression of spirits; sad, weeping mood; 
solicitude about her salvation ; disposition to suicide, but fear 
of death ; chilliness, flashes of heat, cold hands and pale face. 

"While the lachrymose symptoms of this remedy are, in the 
main, characteristic, the drug must be compared with others 
that have the weeping mood. Among these we have ignatia, 
natrum mur., stannum and sepia. For the purpose of com- 
parison we may study Farrington with advantage. 

''The ignatia woman dwells upon her grief in secret; she 
nurses her sorrows and keeps them to herself. In the words of 
Shakspeare, she lets ' Concealment, like a worm i' the bud, feed 
on her damask cheek.' This introspective mood is the opposite 
of Pulsatilla. The Pulsatilla patient makes known her grief to 
everyone who comes near her; she seeks sympathy; she is 
timid and yielding in her disposition. 

"This tender, yielding disposition, that likes consolation, 
differs from natrum mur., in which, with hypochondriasis, con- 
solation seems to make the patient worse. Attempts at 
consolation may even make her angry. 

"The stannum patient is usually sad and lachrymose, just 
like Pulsatilla. Crying usually makes the patient worse. The 
woman for whom stannum is indicated is also nervous and 
weak. Stannum will come in as a prominent remedy in lung 
troubles complicating insanity of pregnancy. 

"Sepia also develops a state of weeping; anxiety with ebul- 
litions ; peevish ill-humor ; solicitude about her health. But with 
all her lachrymose temper, she is easily offended and is inclined 
to be vehement. 

"Stramonium. — The mania of this drug may be of a wild or 
(19) 



290 Pregnancy. 

of a merry character. Delirium with bright, red face ; the eyes 
have a wild and suffused look. Terrifying hallucinations ; the 
patient sees animals springing up from every corner. Loqua- 
cious delirium ; at times a merry mood ; at others she has the 
horrors. Laughing, singing, and making faces one minute; the 
next, praying or crying for help. Desire for company and for 
light, with fear of the darkness. 

"In comparing stramonium, hyoscyamus and belladonna, 
Farrington says: 'Stramonium differs from belladonna and 
hyoscyamus. The patient sees objects which seem to rise in 
every corner of the room and move towards him. He has a 
mania for light and company, which is just the opposite of 
belladonna, is excessively loquacious and laughs, sings, swears 
and prays, almost in the same breath. The desire to escape is 
present ; there is sudden spasmodic lifting of the head from the 
pillow, and then dropping it again. He awakens from sleep in 
fright and terror, not knowing those around him. The motions 
that he makes are quite graceful and easy, although they may 
be violent. At times the body is bathed in a hot sweat, which 
does not give any relief to the patient. The desire to uncover 
is similar to that of hyoscyamus, but it is more an uncovering 
of the whole body than of the sexual organs. The tongue is 
often soft, taking the imprint of the teeth. Screaming in sleep, 
often with hiccough. The face is usually bright red, but not so 
deeply congested as in belladonna.' 

"Sulphur. — Despondency. Religious melancholia, with de- 
spair for her salvation; irritable and taciturn; slowness of 
body and mind during the day ; indisposition to do any labor. 
Mania; she spoils her things and throws themawa} 7 , imagining 
she has everything in abundance. She imagines she has beauti- 
ful dresses ; looks on old rags as beautiful dresses. 

" Veratrum album. — Furious mania. Wild shrieks, protru- 
sion of the eyes ; bluish and bloated face ; anxiety ; frightened at 
imaginary objects; lasciviousness ; lewdness in talk; endeavors 
to kiss everyone. Coldness of the surface of the body, with 
cold sweat on the forehead. 

" Veratrum viride. — Mania with arterial excitement. Eyes 
red ; pulse small but very frequent. This drug has been used in 
a case of acute mania with curative effect after hyoscyamus, 
stramonium, veratrum album and hepar sulphur had been 
used in vain. The symptoms were: loquacity with exalta- 
tion of ideas, or an exalted opinion of her own powers ; every- 



Diseases of Pregnancy. 291 

thing seems clear to her : what had formerly been mysterious 
to her, she now clearly understands; she does not want any 
medicine that will restore her to her former condition: some 
of the time she talks and laughs ; on some days the laughter 
is quite constant ; one day she talks a long time about one 
thing, and again changes that theme to another; will persist 
in continual talk, without heeding what is said to her: will 
not answer questions ; does not like to be disturbed when she 
is talking: she knows all that is going on about the house, 
and does not want anything said which she cannot hear; does 
not want to get up long enough to have the clothes changed ; 
head feels bad: the eyes are red, but vision is not affected: 
appetite capricious : not much thirst ; pulse small and frequent. 
The remedy was used in tincture. 

"In one of Dr. Atlee's cases the patient was stubbornly 
silent, suspicious, and distrustful of those about her. She 
thought the physician had poisoned her, meditating her de- 
struction. 

Eclampsia— All convulsive attacks during pregnancy, par- 
turition and puerperality, are not properly classified under this 
heading, since some of them are manifestations of epilepsy, 
before present, and others incidental symptoms associated 
with other diseases. The true puerperal convulsion is an ex- 
pression of pathological conditions in which the changes inci- 
dent to pregnancy constitute essential factors. 

Puerperal eclampsia is an acute disease occurring in women 
in pregnancy, in labor, or in childbed, often sudden in its on- 
set, rapid in its progress, characterized by convulsions, with 
loss of sensation and consciousness, ending in coma. (Bailly.) 
The term eclampsia, signifying flashes of light, indicates the 
overwhelming force of the attack, and the lightning suddenness 
with which it often sets in. 

Freqeexcy. — The average frequency of eclampsia is about 
one case in three hundred. According to the statistics gathered 
by Dr. George B. Peck, among twenty physicians of our school 
of practice, representing a total experience of three hundred 
and five years, fifty-one cases had been met. It is more fre- 
quently met among primiparse. especially in those well ad- 
vanced in years, in twin pregnancy, in women with contracted 
pelves, and in connection with the birth of male children. It is 
sometimes epidemic. 

Etiology.— The following theories respecting the conditions 



292 Pregnancy. 

which excite eclampsia in pregnancy and childbed have each 
had strong advocates, and each now has its supporters : 

1st. Material change in the nervous centers and their envel- 
opes. 

2nd. Cerebro-spinal congestion. 

3rd. Keflex irritation through the spinal system, of which 
the point of departure is the uterus. 

4th. General or cerebral anaemia. 

5th. Blood-poisoning, which disturbs the normal action of 
the nerve-centers. 

1. Eclampsia is Due to Material Changes in the Nervous 
Centers and their Envelopes. 

From experiments which have been made, it is clearly shown 
that the augmentation of blood-pressure alone is not sufficient 
to bring on the convulsions ; but the serous effusions which re- 
sult — in other words, the cerebral and spinal oedema — have been 
regarded by many as adequate exciting causes. 

2. Eclampsia is Due to Cerebro-Spinal Congestion. 

This theory was held by the older obstetricians, among 
whom is Dr. Hodge, who says that '•convulsions in a large 
proportion of cases arise from a congestion of the blood-vessels 
of the brain, or from an actual effusion of serum or blood into 
its substance or cavities." It has been shown by more recent 
observers that the evidence of cerebro-spinal congestion and 
hemorrhage found in certain autopsies of women who died 
from eclampsia, is the result of the convulsions, and not the 
cause of them. 

3. Eclampsia is a Nervous Disturbance Set Up by Reflex 
Irritation of the Spinal System, the Point of Departure being 
the Uterus. 

This theory has had many advocates of acknowledged 
standing and repute, among whom are Dubois, Scanzoni, Mar- 
shall Had and Tyler Smith. "In conclusion,*' says Tyler 
Smith, "to give a summary of the whole subject, the true 
puerperal convulsion can only occur when the central organ of 
this system, the spinal marrow, has been acted upon by an 
excited condition of an important class of incident nerves, 
namely, those passing from the uterine organs to the spinal 
center, such excitement depending on pregnancy, labor, or the 
puerperal state. While the spinal marrow remains under the 
influence of either of these stimuli, convulsions may arise from 
two series of causes— those acting primarily on the spinal 



Diseases of Prkgnancy. 293 

marrow, or centric causes; and, secondly, those affecting the 
extremities of its incident nerves— causes of central or pe- 
ripheral origin.'' When -we reflect upon the remarkable uterine 
changes which are wrought by pregnancy, and the phenomena 
of parturition, this theory certainly assumes significance and 
importance. "The answers to this theory are," remarks 
Parvin, "first, eclampsia may occur either before or after labor 
when the uterus is in complete repose, not the slightest mani- 
festation of an irritated condition; and,, second, the uterine 
irritation being so much greater in primigravidae, they ought 
to be much more generally the subjects of eclampsia. It is now 
generally held that while uterine irritation may, in some cases, 
assist in causing a convulsive attack, it is not the chief cause of 
the disease ; or even if in a very few cases it may be the chief or 
only cause that can be discovered, it is inadequate to explain 
the majority of cases." 

4. General and Cerebral Ansemia are the Causes of Eclampsia. 
Some writers on the subject have regarded general ansemia, 

and others cerebral anaemia, as the pathological condition upon 
which eclampsia is based. These authorities attribute the 
general anaemia in the main to the albuminuria which they 
assume to exist in all, or nearly all, cases. But our own obser- 
vations, as well as those of many eminent obstetricians, prove 
that albuminuria is by no means an essential antecedent of 
eclampsia. Charpentier has tabulated 141 cases reported by 
forty-five different observers, wherein there was no evidence of 
albuminuria prior to the development of the convulsive seizure. 
And since in a large percentage of cases no examination of the 
urine is made until after attention is drawn to it by the occur- 
rence of convulsions, the question has well been raised whether 
the albuminuria is the cause, or the sequence of the convulsions. 
The cerebral anaemia, which by some is regarded as an 
efficient cause of the seizures, is accounted for, in a measure, by 
irritation of the nerve-centers from circulation through them 
of vitiated blood, thereby giving rise to vaso-motor disturbance, 
resulting in contraction of the cerebral arteries. 

5. Eclampsia is Due to Blood-poisoning, which Benders the 
Vital Fluid Inefficient to Sustain Normal Action of the Nerve- 
Centers. 

Under this head are included mainly uraemia and am- 
moniaemia. It is the most commonly accepted theory, though 
not one upon which we can explain all cases. 



294 Pregnancy. 

We cannot give our exclusive endorsement to any one of 
these theories, inasmuch as we believe that there is no uniform 
pathology back of the phenomena. Indeed, it seems to us 
probable that each of these theories is capable of accounting 
for a certain number of cases. 

Pathological Anatomy. — The lesions which .are met at the 
autopsies of women dead from eclampsia are so numerous a«nd 
various that we may seriously question whether the disease has 
any distinctive pathological anatomy. Sometimes they are in 
the brain, at others in the lungs, and again in the kidneys ; 
hence it is impossible among these to find one lesion which may 
be regarded as characteristic. Such able observers as Kams- 
botham, Velpeau, Scanzoni, Cazeaux, Kiwisch and Jacque- 
mire, have made a certain number of autopsies in such eases 
without discovering any lesions. Braun in one case found in- 
termeningeal apoplexy ; in ten cases anaemia and oedema of the 
brain and its envelopes. In forty-two autopsies made by 
Devilliers, Regnauld, Lever, Hardy, Collins, McClintock, Kams- 
botham, Kiwisch and others, there were ten cases of hyperemia, 
four of anaemia, four of normal vascularity of the brain, seven 
of serous effusions in the arachnoid, five of ventricular hydrop- 
sies, and twelve of apoplectiform extravasations of the brain. 

De Paul, Blot, Bailey, Mercier and Charpentier have noted 
cerebral hemorrhages, and Molas arachnoidal hemorrhages. 
Helm, Kiwisch and Braun have observed hyperaemia of the 
membranes, and meningeal apoplexy. Bloff noticed serous 
effusions in the spinal cavity. 

The alterations most frequently observed are in the kidneys. 
These, however, are not constant, though in many cases they 
may be overlooked for want of thoroughness in the examina- 
tion, or inadequacy of the means employed. The morbid 
changes observed are mainly (1) hyperaemia and slight exuda- 
tion ; (2) exudation and a certain amount of fatty degenera- 
tion; (3) atrophy. 

Dr. Alexander Pilliet lays great stress upon the haemor- 
rhagic foci which are found in the livers of women after death 
from puerperal eclampsia. He infers that the hepatic lesion 
is primary, and that this pathological discovery must modify 
our opinions and our treatment of one of the gravest compli- 
cations of childbed. Twelve necropsies have been made by this 
obstetrician, and in all the characteristic changes in the livers 
were detected. This series does not include any case of cholemic 



Diseases of Pregnancy. 295 

eclampsia or hepatic anaemia of pregnancy and the puerperium ; 
and in the twelve, icterus, where it occurred, was slight, and ap- 
peared after the other distinct symptoms. The hemorrhagic 
foci in the tissues of the liver are no mere product of simple 
engorgement of a vessel followed by rupture. There are asso- 
ciated with complicated local pathological changes, minutely 
described by Dr. Pilliet. In certain respects these foci resemble 
similar appearances observed in the kidney in scarlatinal and 
erysipelatous nephritis. The most careful search, however, has 
failed to detect any bacteria in the foci in Dr. Pilliet's twelve 
cases. He maintains that since a distinct and severe lesion of 
the liver was found in every one of the twelve cases of death 
from puerperal convulsions, it is reasonable to suppose that 
the lesion is pathognomonic of the complication in ques- 
tion. 

Effect on Pregnancy .—This is nearly always decided. The 
morbid conditions existing in the mother and which lead up to 
the development of convulsions, together with the immediate 
effect of the strong convulsive action, nearly always prove de- 
structive to fcetal life. Labor may not immediately ensue, but is 
not long delayed. The duration of labor is somewhat shortened 
by strong uterine action and the relaxation which follows the 
convulsive movements. 

Prodromata. — An attack of puerperal convulsions is nearly 
always preceded by premonitory symptoms, the significance of 
which should be understood. They are not equally valuable as 
indices of the morbid state of the system. The patient suffers 
from sleeplessness, or an inclination to the opposite condition 
of drowsiness ; there may be vertigo, vomiting, ringing in the 
ears, irritability of temper and lowness of spirits. None of 
these, however, are peculiarly indicative of threatened convul- 
sions; but when to them are added severe frontal headache, 
disturbance of vision and epigastric pain, we have the premoni- 
tory symptoms well mapped out before us. 

The headache involves chiefly the sinciput, pain rarely being 
felt in the occiput. It at first is felt at intervals, after a time 
the intermissions become mere remissions, and when the ache 
becomes constant the eclamptic seizure is usually at hand. The 
headache may precede convulsions several days, or only a few 
hours, but is nearly always present for a time before the first 
paroxysm. 

Disturbances of vision are nearly as constant a forerunner 



296 Pregnancy. 

of eclampsia. These are dimness of sight, as though a mist 
were before the eyes, amblyopia, hemiopia and diplopia. 
Blurred vision is the most common, and occasions .the patient 
great annoyance in the performance of her daily household 
duties. On attempting to read, the letters run together or ap- 
pear to be obscured by film before the eyes ; on trying to sew, 
she can scarcely see the stitches. These ocular disturbances 
increase in severity as the patient nears the eclamptic seizure, 
total blindness sometimes developing, and continuing for days. 
Severe pain in the region of the solar plexus is occasionally ex- 
perienced for a few hours before the convulsive attack. In a 
case which came under our care a few years ago, this epigastric 
pain came on severely about two o'clock in the afternoon, in a 
patient seven months advanced in pregnancy, and refused to 
yield to remedies aided by various adjuvants, culminating 
about two hours later in the beginning of a series of convulsive 
seizures which terminated in death. The pain in this instance 
was evidently as severe as that attending an aggravated at- 
tack of bilious colic. 

The Seizure. — This commonly sets in suddenly and vio- 
lently. The patient, totally unaware of the terrible experience 
before her, may be engaged about her ordinary avocations, 
when she suddenly falls to the floor with the muscles set in a 
tonic spasm. The head is usually turned to one side, and the 
eyes appear to be set as though gazing at a fixed object. The 
extremities are extended, the hands firmly closed with the 
thumbs under the fingers. The face becomes livid, and the 
pulse feeble and rapid. Consciousness and sensibility are wholly 
lost, and the pupils do not respond to light. The mouth is 
distorted and usually deviates to the left. The convulsive wave 
extends from above downwards, and involves all the voluntary 
muscles. Whether the muscles of organic life are implicated or 
not is a matter of speculation, but from observations made by 
Braxton Hicks it would appear that the uterus sometimes 
shares in the convulsive action. The tonic stage is soon suc- 
ceeded by the clonic, wherein the body, by the irregular action 
of its various muscles, is thrown and jerked about in a most 
distressing manner. The lividity of the countenance becomes 
more marked, on account of the impeded respiration; breath- 
ing is carried on in an irregular and imperfect manner, and 
through the set jaws frothy saliva is blown out with a bubbling 
sound. The muscles of the face act wildly, which, with the 



Diseases of Pregnancy. 297 

rapidly moving eyes, give the countenance a hideous expres- 
sion. It is the most repulsive sight which the physician, who 
gets " behind the curtain " oftener than anyone else, is called to 
witness. To see a woman in her beauty and strength thus dis- 
torted and disfigured in a moment, is enough to distress the 
most Platonic. The storm of convulsive action slowly dies 
away. The movements become less violent, the lividity fades, 
the eyes slowly close, and after a few more twitchings of smaller 
muscles, relaxation comes to the distressed body so recently 
writhing in the most extravagant manner. 

The duration of an attack varies from one to twenty 
minutes, and the convulsive movement is succeeded by a period 
of coma more or less profound. In some instances conscious- 
ness returns soon after the spasmodic movements cease, but 
generally after the lapse of a longer time. The patient may 
suddenly open the eyes as if in fright, and utter wild screams, 
soon quieting again into the unconscious state, or returning 
slowly to a comprehension of her surroundings, though not at 
first to the realization that anything unusual has happened. 
As a rule, consciousness is restored by degrees, and memory of 
the occurrences preceding the attack returns after several hours. 
Even upon complete restoration to a normal condition, it is 
found that many of the incidents which occurred during what 
appeared to be hours of sanity preceding the seizure, have 
wholly escaped the memory. 

The first attack is nearly always succeeded at irregular 
intervals by others, unless effective measures for prevention are 
at once adopted. Eclampsia may thus be arrested, in some 
instances, after a single attack, while again the most vaunted 
remedies will utterly fail. 

The paroxysms vary greatly in number. The average 
among those who recover is perhaps six or eight. The 
greatest number ever witnessed by Winckel in a case terminating 
favorably was seventeen. Among those ending fatally the num- 
ber may rise to one hundred and sixty. Between attacks the 
coma, which results from cerebral congestion, becomes more 
and more pronounced, deepening towards death. Even in those 
cases which recover, the patients may lie in a state of coma for 
hours. Death sometimes takes place during a paroxysm, but it 
oftener occurs during the comatose stage, as the result of pul- 
monary oedema and cerebral apoplexy. When recovery ensues, 
as it does in the majority of instances, there is a decrease in the 



298 Pregnancy. 

frequency, duration and intensity of the paroxysms, followed 
by a deep, quiet sleep. 

Diagnosis. — To base our diagnosis on the phenomena pre- 
sented by a convulsive seizure, would be unwise. The previous 
history of the patient, not only that immediately preceding 
the attack, but that also of the ante-pregnant state, should be 
learned, and be given due weight in making up our judgment. 

Special inquiry ought to be made concerning epileptic attacks, 
since the phenomena of epilepsy are with difficulty differen- 
tiated from those of true puerperal eclampsia. With the onset 
of an epileptic paroxysm the patient utters a cry, which is 
usually absent in eclampsia ; and after the former the succeed- 
ing coma is more prolonged. 

Less difficulty is experienced in differentiating hysteria. 
During the attack consciousness is not wholly lost, the orderly 
course of the phenomena is broken, wild gesticulation and 
admixture of emotional symptoms usually being sufficient to 
reveal the character of the attack. Moreover, instead of the 
succeeding comatose state which follows the paroxysm of real 
eclampsia, evident consciousness is soon observed, even though 
it is sought to be hidden by the patient. 

Occurrence and Mortality. — " Of the fifty-one cases under 
consideration," says Dr. Peck in his report to the American 
Institute of Homeopathy, in 1884, "in ten the convulsive 
attack anticipated labor ; in thirty it manifested itself during 
labor, while in eleven it occurred not until after the entire com- 
pletion of parturition. In the first class four mothers, forty 
per cent., perished, including one of whom it was at first sup- 
posed she was merely threatened with abortion. (One of the sur- 
vivors suffered for a considerable time with puerperal insanity, 
but eventually recovered her wonted health.) Eight children 
were also lost, eighty per cent., one of which was the offspring 
of the patient just referred to; one the probable victim (though 
the fact was not positively stated) of a premature labor three 
weeks after the spasms, and one was already putrescent at 
delivery. In the second class eight mothers perished, twenty- 
six and two-thirds per cent., one of whom lingered six days 
after labor, and another succumbed to an attack of puerperal 
fever. Here but nine children were lost, or only thirty per cent. 
In the third class two mothers perished, or eighteen per cent. 
One of the survivors, who had six paroxysms within an hour, 
was not attacked until twenty minutes after the birth of a 



Diseases of Pregnancy. 299 

dead child. Combining we find a total loss of fourteen mothers, 
twenty-seven and a half per cent., and sixteen children, omit- 
ting those known to be dead prior to the seizure, or thirty-one 
and a third percent. The maternal mortality in cases occurring 
before or during labor is thirty per cent." 

The results of eclampsia must be held to vary according to 
the severity, frequency, duration and number of the paroxysms, 
as well as the period in the reproductive process at which the 
convulsions set in. Braiin says he has known but one patient 
to recover when attacked between the fourth and sixth months 
of pregnancy, except where abortion took place. When several 
seizures are suffered, the life of the child is nearly always de- 
stroyed, as we have elsewhere intimated. 

Treatment. — Treatment of eclampsia should be considered 
under two heads, viz : Preventive treatment and curative 
treatment. 

Preventive Treatment. — The prodromata of eclampsia have 
been mentioned, the most prominent of which were headache, 
disturbance of vision and epigastric pain. With these may be 
associated, as a still more threatening symptom, albuminuria. 
The first three symptoms are strongly significant, even when 
existing independently of albuminuria, and demand attentive 
consideration and faithful treatment. When there is albumen 
in the urine we are inclined to be influenced overmuch by this 
expression of pathological change to the neglect of other symp- 
toms which may not be dependent upon the albuminuria nor 
directly connected with it. The subjective, as well as the ob- 
jective, symptoms deserve to be accorded due weight, if we 
expect to give our patients the most perfect protection from the 
impending attack. It is under such circumstances as these that 
the value of our law of cure is able to manifest, with unusual 
force and beauty, its truth and efficiency. Of course the woman 
should be brought under the influence of good sanitary condi- 
tions, so that nature may not be handicapped in her efforts to 
restore the disordered system to perfect harmony. Among the 
remedies more especially suited to the cephalic, the ocular and 
the epigastric regions, when presenting the symptoms before 
mentioned, are the following : 

Belladonna. — This remedy covers the symptoms more 
thoroughly and more frequently than any other. The head- 
ache is chiefly in the sinciput, of a congestive, pressive, boring, 
throbbing, or even lancinating character, worse from stooping, 



300 Pregnancy. 

from movement in general, from lying. The eyes have dimness 
of vision, bright sparks and flashes before the eyes, and double 
vision. This remedy also has the epigastric pain. Pain in the 
stomach, extending through to the spine, is one of its most 
characteristic indications. 

Gelsemium. — We place this remedy as secondary only to 
belladonna for the premonitory symptoms of eclampsia. 
Neither of these has any special relation to albuminuria, which 
may or may not be present. Our reference here is only to the 
symptomatology of the case, to follow which as a guide in the 
selection of remedies under these circumstances we regard as the 
safer and more effective course. The headaches of this remedy 
are chiefly in the occiput, while those accompanying other symp- 
toms of a premonitory nature in these dangerous cases are usual- 
ly in the sinciput. Still the gelsemium headache is not confined 
to the occiput, but this part of the head sometimes escapes 
while the sinciput suffers. The headache is of a severe type, is 
accompanied with a sore bruised feeling, depression of the 
mental faculties, vertigo, dimness of vision from a haziness 
before the eyes, diplopia, hemiopia and even total loss of sight. 
The remedy covers likewise the severe epigastric pain which 
sometimes precedes by a few hours the convulsive seizure. 

Glonoinum. — Here is a remedy which does not correspond so 
closely with the symptoms of these cases as usually manifested, 
and yet one capable of affording relief in some instances. 
Among its indications are the following: Fullness in head as 
if all the blood had mounted to it ; throbbing in front head ; 
crushing weight across forehead ; pressure and throbbing in 
temples ; holds head with both hands on the sinciput ; flashes 
of light before the eyes; eyes red; and violent pains in the 
epigastrium. Each of the above remedies has insomnia well 
marked, and this is often a most distressing symptom in asso- 
ciation with those already mentioned. 

Among other remedies which may be indicated by the more 
prominent precursory symptoms, are these, arsenicum, bry- 
onia, mix vomica, melilotus and cicuta. 

Albuminuria constitutes one of the most threatening symp- 
toms, but its treatment has been described at some length in 
an other, place, and therefore requires no special consideration 
here. We may add, however, that the above-mentioned reme- 
dies, though not all of them peculiarly suited to the relief of 
albuminuria, as viewed from a physiological standpoint, may 



Diseases of Pregnancy. 301 

jet afford perfect results in that direction, if specially indicated 
by other symptoms. Likewise, the remedies named under al- 
buminuria may cure the accompanying headache and other 
disturbances. 

Curative Treatment. — It will be modified more or less by the 
period at which the convulsions are developed. 

When eclampsia sets in during pregnancy, and the paroxysms 
are not brought under control, the question of inducing labor 
has to be settled. The advisability of the operation is advo- 
cated by some and denied by others; and in the absence of a 
settled rule of action, the question will have to be considered 
and settled in individual cases as they arise. It certainly ought 
not to be undertaken unless other measures have utterly failed, 
for the results of the operation, as thus far observed, are not 
reassuring. 

In many instances the uterus is excited to action by the 
convulsions, and dilatation of the os begins, the case being 
resolved thereby into one of eclampsia during labor, to be 
managed accordingly. 

Convulsions which set in after labor has begun have a tend- 
ency to recur until the parturient act is completed, and then to 
cease. It is therefore advisable to hasten delivery by every 
obstetrical resource which is not inimical to the woman's safety. 
During the first stage the means at command are rupture of the 
membranes, catheterization of the uterus, and manual dilata- 
tion ; and during the second stage, use of the forceps. In case 
of malpresentation, or of a certain degree of contraction of the 
pelvic brim, it may be advisable to practice podalic version be- 
fore complete dilatation of the os uteri. 

" At the recurrence of the fit," says Dr. R. Ludlam," a thick 
piece of india rubber, or of soft wood, should be placed between 
the teeth, in order to protect the patient's tongue. She should 
not be held forcibly or firmly to the bed, but simply prevented 
from throwing herself on the floor or otherwise inflicting bodily 
injury. Too much constraint might increase the difficulty, and 
would do no good. If she has an antipathy to the nurse, the 
husband, or anyone in the room, you had better send them 
out. And do not let bystanders give vent, in her hearing, to 
exclamations of fright and horror at the contortions of which 
they are witnesses." 

Therapeutics. — Among the curative remedies for this dis- 
ease, none occupies so prominent a place as belladonna. "No 



302 Pregnancy. 

remedy," says Baehr, " responds to this disorder as completely 
as belladonna." The indications for its use, according to 
Guernsey, are as follows : She has the appearance of being 
stunned; a semi-consciousness and loss of speech; convulsive 
movements in the limbs and muscles of the face; paralysis of 
the right side of the tongue; difficult deglutition; dilated 
pupils ; red or livid countenance. She may have paleness and 
coldness of the face, with shivering ; fixed or convulsive eyes ; 
foam at the mouth ; involuntary escape of the faeces and urine ; 
renewal of the fits at every pain ; more or less tossing between 
the spasms, or deep sleep with grimaces; or starts and cries 
with fearful visions. The efficacy of belladonna has been 
repeatedly demonstrated. 

Cicuta, virosa. — We have found but little reported experience 
with this remedy in eclampsia, but we believe it one of great 
promise. It has, as we have before shown, the symptoms which 
usually precede an onset of the convulsions, and from these 
alone would be well indicated ; but, in addition, it has loss of 
consciousness; facial distortion, either horrible or ridiculous; 
red, bluish, puffed countenance; dilated pupils and insensibility 
of the eyes to light; eyes staring, fixed and glassy,, or up- 
turned ; convulsions, with loss of consciousness, frightful 
distortion of limbs and whole body. 

Gelsemium. — This has proved to be a remedy of remarkable 
value in this disorder. It is especially indicated when attacks are 
excited through reflex causes. One of its prominent symptoms, 
sometimes observed as premonitory of an attack, is a large 
feeling of the head. The pulse is full, but not usually hard ; or 
it may be rapid and feeble. For some hours before the attack, 
and in the intervals, she is extremely dull. 

Veratrum viride. — The strongest indication for this remedy 
is found in high arterial tension and circulatory excitement. 
Apart from these indications, it has been used, in great 
measure, empirically ; still it has done much good service. 

Following are indications for other remedies, many of which, 
when thereby chosen, have often proven efficacious: 

Argenticum nit. — Seizures preceded by restlessness, and a 
sensation of general expansion, especially of head and face. 

Cocculus. — Convulsions following difficult labor, and those 
which appear to be brought on by changing position ; before 
the attack the patient complains of a sense of great weakness, 
especially of the lower limbs. 



Diseases of Pkegnancy. 303 

Cuprum met.— Spasms during pregnancy, of a clonic nature, 
beginning in one part and spreading; convulsions during 
parturition, with violent vomiting, or with every paroxysm 
opisthotonos, spreading of the limbs and opening of the 
mouth. 

Gionoinum — Unconsciousness; face bright red, puffed; full, 
hard pulse; urine copious and albuminous. 

Helleborus. — Convulsions, with scanty urine; urine dark, 
floating dark specks, or albuminous. 

Hyoscyam us. —Shrieks, anguish, chest oppressed; uncon- 
sciousness; jerking of every muscle in the body, including 
those of the eyes, eyelids and face; convulsions preceded by 
insomnia. 

Opium.— Convulsions during and after labor; drowsiness, 
open mouth, coma between paroxysms; convulsions which 
appear to have been excited by fright or grief; stertorous 
respiration sets in soon after convulsions begin. 

Pulsatilla. — Convulsions following sluggish or irregular labor 
pains; unconsciousness; cold, clammy, pale face; stertorous 
breathing, full pulse. 

Secale. — Labor ceases and convulsions begin. 

Stramonium.— Bright light, or contact, renews the parox- 
ysms; arouses with a shrinking look, as if afraid of the first 
object seen. 

We do not feel that an account of remedial measures would 
be ample without allusion to other remedies than those already 
mentioned, and some, too, which, in their common use, are 
chiefly palliative. Our law r of cure is probably universal in its 
application, but it is still so imperfectly understood in its de- 
tails that, to rely implicitly and exclusively upon it, in the 
presence of a dire emergency, is scarcely justifiable. These 
remedies which follow are not recommended to substitute 
homeopathic medication, but as mere expedients, by means 
of which to gain time for the selection and exhibition of the 
true similimum. 

As a temporary expedient, to prevent the early recurrence 
of a convulsion, chloroform may be used to the extent of com- 
plete narcosis ; but it is not a remedy whose action can safely 
be long maintained. 

Chloral hydrate is a remedy wiiich will produce an effect on 
the system similar to that of chloroform, and may be continued 
for an indefinite period. Tn such cases it cannot well be admin- 



304 Pregnancy. 

istered by the mouth, but its effect can be as effectually secured 
through the rectum. The bowel should be cleared through the 
use of an enema, and then the chloral injected in the dose of 
sixty to one hundred grains. This may be repeated once, twice 
or thrice, if necessary, within a few hours. The usual formula 
for the injection is : 

New milk . . . ... . . oz. iij. 

Egg ■ one yolk. 

Chloral hydrate grs. xc. 

To a homeopath this may seem like heroic dosing, but for 
the purpose named, a much smaller quantity of the drug would 
have little effect. 

Opium has been highly praised for its effect to quiet the 
perturbed nervous system in these desperate cases. It is best 
administered in the form of morphia by hypodermic injection. 
One-fourth to one-half grain, in repeated doses, is sometimes 
used. This mode of treatment has received strong endorsement 
from old-school authorities. 

Reliable statistics representing the results of various forms 
of treatment are not easily obtained; but from all we can 
gather on the subject, we are fully justified in saying, that, 
as between the two prominent modes of treatment upon which 
the old-school has learned to rely, namely, that by opium and 
that by chloral, the advantage appears to be on the side of 
chloral. 

We regard the hot wet pack as a most valuable agent in the 
treatment of eclampsia. Seemingly hopeless cases sometimes 
yield to it. It should be given by wringing out four blankets 
ifrom hot water and wrapping all but the head in them. Upon 
the latter should be laid cloths wrung from ice-cold water. 

Under any form of treatment the mortality is appalling. At 
the same time later reports indicate improvement in this direc- 
tion, proceeding largely, no doubt, from the growing custom of 
women to place themselves under the care of physicians during 
gestation. 

Relaxation and Disruption of the Pelvic Articulations — 
Relaxation, or violent disruption of the pubic joint and of the 
ilio-sacral synchondroses, has been described by several. The 
symptom most characteristic of such cases is the difficulty, or 
impossibility, of sitting or standing erect. There is pain or 
uneasiness in the pelvic region, and a sense of weakness and un- 



Diseases of Pregnancy. 305 

steadiness in the bones, with a sense of relief afforded by a tight 
bandage about the hips. Such a bandage, and absolute rest, 
constitute the best treatment. 

Inflammation and suppuration of the pelvic joints are occa- 
sional occurrences. When recognized, the pent-up matter should 
be drawn away, and constitutional treatment adopted. 
(20) 



PAET III. 
LABOR. 



CHAPTER I. 

CAUSES AND CHARACTER OF LABOR. 

We have glanced at the phenomena associated with impreg- 
nation ; we have traced the growth and development of the 
foetus to maturity; we have considered the diseases and acci- 
dents to which the foetus is liable; the phenomena and manage- 
ment of its premature expulsion, and we now come to that part 
of our subject which treats of its expulsion at the close of 
mature utero-gestation, a period which, in the human female, 
is accomplished in about ten lunar months from the date of 
impregnation. 

The Causes of Labor. — " Speculation as to the proximate 
causes of labor," writes Lusk, who reasons very learnedly on 
the subject, "have so far proved profitless. The following par^ 
ticulars comprise the extent of our knowledge of the condi- 
tions which prepare the way during pregnancy for the final 
expulsive efforts : 

" 1. During the first three months the growth of the uterus 
is more rapid than that of the ovum, which is freely movable 
within the uterine cavity, except at its placental attachment. 
In the fourth mouth the reflexa becomes so far adherent to the 
chorion that it can only be separated by the exertion of some 
slight degree of force, and the amnion is in contact with the 
chorion. After the fourth month the chorion and amnion are 
agglutinated together, though even at the termination of preg- 
nancy they may with care be separated from one another. 
After the fifth month the agglutination of the decidua vera and 
reflexa takes place. In the second half of pregnancy the rapid 
development of the ovum causes a corresponding expansion of 
the uterine cavity, the uterine w r alls becoming thinned, so that 
by the end of gestation they do not exceed upon the average 
two or three lines in thickness. The vast extension of the 
uterine surface is not, however, simply a consequence of over- 
stretching, a fact shown by the circumstance tnat the uterus 

(307) 



308 Labor. 

towards the close of gestation is increased nearly twenty -fold in 
weight, and by the histories of extra-uterine foetations, in which, 
up to a certain limit, the uterus enlarges progressively, in spite 
of the non-presence of the ovum. The augmented weight of 
the uterus is the result of the increase in length and width of 
the individual muscular fiber-cells, the extreme vascular de- 
velopment, and the abundant formation of connective tissue. 
Up to the sixth and a-half month there has further been observed 
a genesis of new fiber-cells, especially upon the inner uterine 
surface. According to Ranvier, the smooth muscular fibers 
become striated as the end of gestation is reached. 

" The precise manner in which the distension of the uterus is 
accomplished has as yet not been demonstrated. A priori only 
two possibilities are apparently admissible, namely, either the 
individual structure elements are stretched after the manner of 
elastic bands, or a rearrangement of the muscular elements 
takes place in such wise that a certain proportion of the fiber- 
cells, instead of lying, as in the beginning of pregnancy, paral- 
lel to one another, gradually, with the advance of gestation, 
are displaced, so that the ends only are in juxtaposition. It is 
possible, though not proved, that towards the close the thin- 
ning of the walls is the result of both conditions. Bearing 
these premises in mind, it becomes a disputed question as to 
whether one of the causes of labor is not to be found in the 
reaction of the uterus, as a hollow muscular organ, from the 
extreme tension to which its fibers are ultimately subjected. 
Countenance to the affirmative side is afforded by the tendency 
to premature labor in hydramnion and multiple pregnancies, 
in which a high degree of tension is reached at a period consid- 
erably antedating the complete development of the foetus. 

"2. There is a perceptible increase of irritability in the 
uterus from the very beginning of gestation. Indeed, the 
facility with which contractions may be produced by manipu- 
lating the organ through the abdominal walls has been put 
forward by Braxton Hicks as one of the distinguishing signs of 
pregnancy. This irritability is especially marked at the re- 
currence of the menstrual epochs, and becomes a more and more 
prominent feature in the latter months, when spontaneous 
painless contractions are ordinary incidents of the normal 
condition. 

"3. The researches of Friedlander, Kundrat, Engelmann and 
Leopold have demonstrated that the deciduavera of pregnancy 



Causes and Character of Labor. 



309 



is distinguishable into an outer, dense, membranous stratum, 
composed of large cells resembling pavement epithelia, proba- 
bly metamorphosed cylindrical cells, and an (in appearance) 
underlying meshwork, formed from the walls of the enlarged 
decidual glands. It is in this spongy layer that the separation 
of the decidua takes place, the fundi of the glands persisting, 
even after expulsion of the ovum. By many, a fatty degenera- 
tion of the cells of the decidua has been observed towards the 
end of pregnancy, but Leopold, Dohrn, and Langhans have 
shown that this is not of constant occurrence. The trabecular 
which enclose the spaces of the network, diminish in size with 
the advance of pregnancy. Thus, while they measure at the 
fourth month about 1.500 of an inch in thickness, they become 




Fig. 124. — The Uterine Mucous Membrane. A, amnion. R, reflexa. D, 
decidua vera. D R, glandular spaces of the lower stratum. M, muscular 
structure. (Englemann,) 

gradually reduced in the subsequent months to 1.2500 of an 
inch, a change which materially facilitates the peeling off of the 
decidual surface. 

"4. From the fifth month onwards, large-sized cells make 
their appearance in the serotina, especially in the neighborhood 
of thin-walled vessels. The largest of these so-called giant-cells 
contain sometimes as many as forty nuclei. Though a physio- 
logical product, they resemble, for the most part, the so-called 
specific cancer-cells of the older writers. They are of special 
obstetrical interest from the fact observed by Friedlander, and 
confirmed by Leopold, that they penetrate the uterine sinuses 
from the eighth month, and lead to the coagulation of the 
blood, and to the formation of young connective tissue, by 
means of which a portion of the venous sinuses become obliter- 



310 Labor, 

ated before labor begins. The subtraction of these vessels 
from the circulation tends to increase the amount of the venous 
blood in the intervenous spaces of the placenta. 

"5. It is proper to recall here the fact that the nerve fila- 
ments of the uterus are derived, in principal measure, from the 
sympathetic system. The large cervical ganglion, which in 
pregnancy measures about two inches in length by one and 
a-half inches in breadth, receives, however, in addition to the 
sympathetic fibers, the second, third and fourth sacral nerves. 

"Physiology has as yet left unsettled the question as to the 
main channels of the motor impulses which are conveyed to the 
uterus during labor. One of my hospital patients, with pa- 
ralysis of the lower extremities, retention of urine, and loss of 
power over the sphincter ani muscle, had a perfectly natural 
though painless labor. The cause of the paralysis was 
obscure, the patient subsequently making a complete recovery. 
Jacquemart reports a similar case, in which the paralysis was 
due to partial compression of the cord at the level of the first 
dorsal vertebra. On the other hand, Schlesinger has shown 
that the sympathetic is not the only motor nerve, as reflex 
movements of the uterus follow stimulation of the organ when 
all the branches of the aortic plexus have been carefully divided. 

" A motor center for uterine contractions has been proved to 
exist in the medulla oblongata. This center is excited directly 
to action by anaemic conditions, and by the presence of carbonic 
acid in the blood conveyed to it. Vivid mental emotions may' 
either awaken or suspend uterine contractility. 

"Reflex movements of the uterus may be provoked by 
stimulating the central end of the spinal nerves, — a fact which 
serves to explain the consensus long recognized as existing be- 
tween the breasts and the organs of generation. When the 
spinal cord is divided below the medulla oblongata, this phe- 
nomenon is no longer observed. Direct stimuli to the uterus, 
however, determine contractions independently of the medulla 
oblongata, the spinal cord then acting as a reflex center. The 
presence of asphyxiated blood in the arterial trunks acts as a 
physiological stimulus to labor. By the separation of the 
decidua from its organic connection with the uterus, the ovum 
acts as a foreign body, and, as is w 7 ell known, speedily awakens 
uterine movements. Finally, Kehrer has shown that, when a 
cornu is removed from the uterus during labor, rhythmic con- 
tractions of the muscular fibers will continue from a half-hour 



Causes and Character of Labor. 311 

to an hour after separation, provided only the tissues be kept 
moist and at a suitable temperature. 

"The following theory of the causes of labor is offered, not 
because of its completeness, but merely as a means of grouping 
the foregoing facts together in the order of their relative im- 
portance. The advance of pregnancy is associated with in- 
crease in the irritability of the uterus, a property most 
pronounced at the recurrence of the menstrual epochs. By 
thinning of the partitions between the glandular structures the 
way is prepared, as the time for labor approaches, for the easy 
separation of the dense inner stratum of the decidua. The 
ready response of the uterus to stimuli reflected from the 
peripheral extremities of the spinal nerves, to direct local irri- 
tation, and to the presence of blood surcharged with carbonic 
acid in the uterine vessels, explains the frequency of painless 
contractions for days, or even weeks, in some cases, previous 
to labor. To these means of exciting uterine motility there 
should be added, in all probability, the reaction of the uterine 
muscle, from the tension to which it is subjected by the growth 
of the ovum, and to the circulatory disturbances in the cerebral 
centers sometimes effected by vivid emotions. Frequently re- 
peated uterine contractions, without partial separation of the 
decidua, are hardly comprehensible after the decidua vera and 
reflexa are brought into close contact with one another. Such 
a physiological separation would, of necessity, when of suffi- 
cient extent, by converting the ovum into a foreign body, fur- 
nish an active cause for the advent of labor, in the same way 
that labor is prematurely excited by a similar separation when 
artificially induced. Thus, by the time the development of the 
foetus is completed, all things are in train for its expulsion. 
When other causes do not early operate as determining forces, 
the increase of uterine irritability at the recurrence of the men- 
strual epochs probably accounts for the ordinary coincidence 
of labor with the tenth catamenial date." 

The Expelling Powers.— The power by which expulsion of 
the foetus is effected resides chiefly in the uterine muscular 
structures themselves. While this is true, every attentive clini- 
cal observer soon learns that much aid is afforded by the 
abdominal muscles, and a little by the feeble contractions of 
the vagina. 

The Uterine Contractions.— The general form of the uterus 
towards the close of utero-gestation is oval; but when in a 



312 Labor. 

state of contraction the longitudinal and transverse diameters 
are diminished, while the antero-posterior is increased, render- 
ing the organ more globular. One very marked feature of the 
uterine efforts is their intermittent character, coming and go- 
ing at gradually narrowing intervals. The action is also peri- 
staltic, beginning at one extremity and sweeping to the other 
in a powerful wave of muscular energy. Whether this action 
proceeds from fundus to cervix, or from cervix to fundus, is still 
a matter of dispute. It is said by most careful observers that 
the contraction sets in at the fundus and flows to the cervix, 
whence it returns in a wave to the fundus, and this accords 
with the author's observation. As the Augers rest against the 
presenting head, the first indication of an approaching con- 
traction is found, not in the patient's uneasiness, nor in the 
contraction of the cervical muscles, but in descent of the 
presenting part into the pelvis. We are often able to notify the 
patient of the coming pain before she herself is aware of its ap- 
proach. This clinical observation is good evidence that the 
contraction does not begin in the cervix. W^e have also found 
that, if one hand be placed on the fundus uteri and the fingers 
of the other on the cervix, contraction will be first felt at the 
fundus of the organ. 

Uterine contraction, of a forcible character, is nearly always 
accompanied by pain, in the early stage of a cutting and saw- 
ing nature, in the second stage of a bearing and disruptive 
sort. At the same time it should be remembered that contrac- 
tions of a forcible kind only are usually painful, contractions 
without pain occurring throughout the greater part of preg- 
nancy without producing any unpleasant sensation. 

Uterine action rarely sets in with force and energy, but in an 
indolent and feeble manner, owing probably to the weakness of 
the stimulus exerted at the beginning. Slowly the contractions 
gather strength and energy, until, at the close, they become 
terrific. The limit of intra-uterine development having been 
reached, and the foetus having become in a sense a foreign body, 
nature begins in a mild and hesitating way to suggest that it 
leave the nidus which it has outgrown. The repeated contrac- 
tions begin dilatation of the os uteri, the relations between the 
uterus and membranes are more and more severed, and in this 
manner a stronger reflex action is excited. At a later period 
the stretched cervix, the distended vagina and vulva, and the 
compressed nerves, augment the action to an almost unbear- 



Causes and Character of Labor. 313 

able degree. At the beginning the pains may be separated by 
an interval of an hour ; but as they increase in force they return 
at shorter intervals, until, during the latter part of the propul- 
sive stage, they may be almost continuous. The average dura- 
tion of a labor-pain is about one minute, or perhaps a little 
less. Contractions come and go without consulting the will of 
the patient who is fortunate enough to be the subject of them, 
and are unresponsive to her volition. The motor centers of the 
uterus are located chiefly in the s} r m pathetic ganglia. It has 
been suggested that the anterior sacral nerves may perform an 
inhibitory office. 

When the membranes are unruptured, the bag of waters, 
being the part in advance, is made to press at the os uteri and 
gradually expand it. If the membranes are ruptured, the 
presenting part of the foetus performs the office, and usually 
performs it nearly as well. Prior to the beginning of labor the 
internal os yields to a considerable degree, so that a few pains 
usually suffice to make the cervical canal a part of the uterine 
cavity. The external os follows, and, before dilatation is com- 
pleted, the lips of the os become extremely thin from the 
stretching imposed upon them. After the bulk of the head 
passes the cervix, retraction of the os from the head rapidly 
follows, and the foetus lies with its head in the vagina and its 
trunk in the uterus, the two cavities thus being opened to form 
a common canal. 

By placing the hand on the globe of the uterus, as it con- 
tracts with force during labor, we may readily determine that 
the uterus displays much energy and contractile power. This 
power of the uterus is more sensibly felt when the hand is 
introduced into the organ for such a purpose as version, while 
the patient is not under the influence of an anesthetic. The 
contractions vary much in intensity, both in different cases and 
in the various stages of the same case. Just what the degree of 
power thus exerted is in different subjects has long been a 
matter of curious inquiry, and attempts have been made to 
measure it. While the results of such researches have not been 
highly satisfactory, owing to the difficulties surrounding the 
investigations, they may be accounted valuable data. Dr. 
Matthews Duncan, after repeated experiment and study, found 
that the force required to rupture the strongest membranes, 
with an os uteri 4.50 inches in diameter, was about 37% pounds,, 
He collected, further, that, in ordinary labor, the propelling 



314 Labor. 

force is from six to twenty-seven pounds. In cases where un- 
usual effort is made, the propulsive power exerted by the uterus, 
the abdominal walls, and the other forces at the woman's com- 
mand, may be increased to eighty pounds. Poppel found that 
an average force of five pounds is required to rupture the mem- 
branes when the dilatation has attained a diameter of 1.9 
inches. He found that the average force necessary for expulsion 
of the foetus varies from four to nineteen pounds. Kibemont's 
experiments showed that when the diameter of the os amounts 
to 3.9 inches, the average pressure necessary to produce rupture 
is twenty-three pounds. Schatz, who entered into a thorough 
scientific investigation of the question, arrived at the conclu- 
sion that the power necessary to accomplish fcetal expulsion 
varied from seven to fifty -five pounds. 

Effect of the Pains on Mother and Fwtus. — One very marked 
effect of the uterine contraction is increase of the arterial 
pressure. This probably grows out of the restriction of circu- 
lation through the uterine walls. But, since there is a great 
degree of nervous excitement associated with the movement, 
the rapidity of pulsation, instead of being diminished as usual 
in proportion to the degree of increased tension, is increased. 
The respirations are usually diminished in frequency, but some- 
times, especially in nervous sensitive women, the increase is 
quite marked. The temperature is slightly elevated, and the 
urinary excretion, in consequence of the arterial pressure, is 
augmented. 

The foetal circulation is decidedly affected by the uterine 
contractions, so that, during a pain, the heart-sounds are 
scarcely audible, even in those cases wherein they at othertimes 
are unusually distinct. This action on the heart is attributed by 
Schwartz to an increased intra-cardiac pressure, by Schultze to 
slight asphyxia, from placental compression, and by Kehrer to 
compression of the cranium and its contents. 

Vaginal Contractions. — As the presenting part of the foetus 
passes through the os uteri and enters the vagina, it at first 
meets with resistance. Distension becomes so great as tempo- 
rarily to paralyze the force of the few muscular fibers of this 
tube; but, after the moment of greatest distension is passed, 
they regain a certain amount of the lost energy and contract 
down upon the receding foetus, and ultimately aid in expelling 
the placenta. 

Abdominal Aid. — The aid afforded by the abdominal mus- 



Causes and Character of Labor. 315 

cles has a marked effect on the progress of labor, but it is not 
invoked until the advent of the propulsive stage. The action 
of these muscles differs from that of the uterus, in that it is in 
a measure voluntary. Still, it is found that, at the height of 
a bearing-pain, the action partakes of the nature of tenesmus, 
and becomes absolutely uncontrollable. Contraction of the 
abdominal muscles aids in the following way : The extremities 
are pressed against some firm support, or otherwise fixed, and 
the trunk is thus rendered firm ; then by deep inspiration the 
diaphragm is pushed downwards while the abdominal muscles 
are held tense, and a powerful downward pressure is thus ex- 
erted on the uterine contents. The aid thus afforded is of the 
greatest value in the accomplishment of rapid and effectual 
parturition. 

The Pains of Labor. — The location and character of labor- 
pains vary not only with the parturient stages, but also with 
the woman's peculiarities. In sensitive women they are ex- 
tremely agonizing, and sometimes overwhelming; wmile in 
those of more obtuse sensibility they are not so keenly felt. 
During the first or preparatory stage the pain is of a cutting, 
sawing or grinding nature, and is felt chiefly in the hypogas- 
tric, or lumbo-sacral region, or in both. From the back the 
pains radiate forwards and downwards into the abdomen and 
thighs. The hypogastric pains extend into the groins. Dur- 
ing the second stage of labor the lumbo-sacral region is, as a 
rule, the seat of greatest suffering, until, towards the close, it 
is transferred to the sacrum, rectum, and vulva. The pains 
themselves are greatly changed during this part of labor, be- 
coming of a tearing, distensive, luxative character. Meigs 
offers some very excellent observations on this subject. " The 
pain felt in labor," he says, "is owing to the sensibility of the 
resisting, and not to that of the expelling, organs. Thus the 
sharp, agonizing and dispiriting pains of the commencement of 
the process, which are called grinders, or grinding-pains, are 
surely caused by the stretching of the parts that compose the 
cervix and os uteri and upper end of the vagina. Pains are 
rarely felt in the fundus and body of the organ ; and nineteen 
out of twenty women, if asked where the pain is, will reply that 
it is at the lower part of the abdomen, and in the back, — indi- 
cating, with their hands, a situation corresponding to the brim 
of the pelvis, and not higher than that, — a point opposite the 
plane of the os uteri. When the pains of dilatation are com- 



316 Labor. 

plebed, and the foetal presentation begins to press upon the 
lower part of the vagina, the pain will, of course, be felt there, 
and is finally referred to the sacral region, the lower end of the 
rectum and perineum. The last pains which push out the 
perineum, and put the labia on the stretch, will of course be 
felt in those parts chiefly. The sensation, under these circum- 
stances, is represented as absolutely indescribable, and cer- 
tainly as comparable to no other pain." 

Meigs was an excellent clinical observer and teacher, but, in 
a fair view of all the facts, it does not seem probable that the 
foregoing is altogether true. Keasoning from analogy, we infer 
that a forcible contraction of an organ like the uterus is, in 
itself, productive of more or less pain. This inference is justly 
derivable from a study of after-pains, and from violent con- 
tractions of other organs. There are other clinical observa- 
tions which throw some light on this question, among which 
we may mention the phenomenon of misplaced or metastatic 
labor-pains. In these cases, the pain, instead of being located 
in its usual place, is felt mainly, or exclusively, in other parts 
of the body. The head, the eyes, the legs, or indeed almost 
any part, may be the point of attack. Dr. B. Fordyce Barker 
reported a case to the New York Obstetrical Society, a number 
of years ago, in substance as follows : He recently attended a 
lady in her confinement who was in labor but two hours, 
though the pains did not seem at any time to center about the 
pelvis. There were no uterine pains at all, but, with each con- 
traction of the womb, pain was experienced in the legs. The 
pain was not localized, nor was there any muscular contraction 
of the legs. The same pain was produced in pressing off the 
placenta. Weigand relates a case in which severe infra-orbital 
pain occurred with every uterine contraction. Dewees mentions 
one in which the pains were felt in the calves of the legs. 

Mattei attributes the lumbar pains to pressure of the uterus 
against the spinal column, and Beau to lumbo-abdominal neu- 
ralgia, like that accompanying uterine troubles disconnected 
with pregnancy. 

The pains of labor increase in intensity as labor progresses, 
but, as a rule, those of the propulsive stage are borne with 
more fortitude than those of the first stage. Lamentations are 
nearly always louder and more touching during the stage of 
dilatation, and the nervous symptoms are at this time more 
prominent. The reason for this is probably found in the 



Causes and Character of Labor. 317 

absence of any appreciable advancement during this stage, and 
the consequent discouragement growing out of the feeling that 
all the pain is of no avail. The fact also that the effort is of 
an involuntary sort, has the effect to make the suffering more 
unbearable than that accompanied by a strong voluntary 
struggle. 

The terms " forcible pains," "weak pains," " deficient pains," 
etc., are commonly used to characterize different phases of the 
distressing process. It will be understood that the substantive 
" pain" is here synonymous with "contraction." Pain is merely 
the sensible evidence of uterine action. When the organ con- 
tracts with energy, the pains are usually severe ; and When it 
acts feebly, the pains are correspondingly light. The terms 
"vehement," "powerful," "forcible," "weak," "deficient," 
"inefficient," etc., are only relative, that is to say, they do not 
express a definite degree of either quality or quantity. 



318 Labor. 

CHAPTER II. 

CLINICAL COURSE AND PHENOMENA OF LABOR, 

The Stages of Labor. — By what has preceded we have been 
brought to a point where it is proper to enter upon a consider- 
ation of the clinical course of labor in its normal phases. 

One cannot long be in the active practice of obstetrics with- 
out observing that the process of parturition is very naturally 
divided into distinct stages, each characterized by its own 
peculiar phenomena, and the whole linked together into a 
remarkably uniform sequence of events. The first is in a 
measure a preparatory stage, during which the pains operate 
to open up the os uteri, and get things in order for descent of 
the foetus through the parturient canal. The second is the 
stage of propulsion, during which "the foetus journeys through 
the pelvis and emerges at the vulva. The third comprises 
separation and expulsion of the secundines. The first stage 
ends, then, with full dilatation of the os uteri ; the second with 
complete expulsion of the foetus ; and the third with separation 
and extrusion of whatever of the product of conception and 
the immediate result of it is left behind. 

The First Stage. — This properly begins with development 
of the first symptoms of actual labor, though the precise mo- 
ment cannot always be determined. There is a certain amount 
of preliminary action which has been very properly termed the 
preparatory stage. This is often well marked, while at other 
times it is so indistinct as to escape detection. 

One of the most common changes occurring toward the 
close of pregnancy is what has been elsewhere alluded to as 
subsidence of the uterus, with a falling forwards of the fundus. 
When well marked, this change of relations and position is fol- 
lowed by considerable relief of the gastric disturbances which 
so often render the woman most uncomfortable in the latter 
part of pregnancy. Locomotion may for a time be more diffi- 
cult, while downward pressure of the uterus produces a frequent 
desire to urinate, and often, to defecate. Proceeding partly 
from this cause, and partly from interference with the portal 
circulation by general intra-abdominal pressure, hemorrhoids 
are liable to make their appearance for the first time, or, in old 
cases, become greatly aggravated. This subsidence of the 



Phenomena of Labor. 319 

uterus is commonly more marked iu primiparse than in rnulti- 
parte, and hence we find the presenting head, covered by the 
uterine walls, low in the pelvis more frequently in the former 
than in the latter. Subsidence of the fundus uteri is not 
brought about, however, wholly by a descent of the whole 
organ, but there is likewise a lessening to a small degree of the 
longitudinal measurement of the same, as though the organ 
were gathering itself for the final struggle. 

For a variable time before the advent of labor, the woman 
usually observes a muco-sanguineous discharge from the 
vagina, accompanied by a sense of dragging in the sacrum and 
pubis, and of tension in the abdominal region. Moreover, as a 
result of the painless uterine contractions which go on through- 
out the greater part of pregnancy, and an aggravation or 
augmentation of which constitutes labor, the cervical canal 
may become dilated, in multipara?, to a considerable degree 
several days before labor. 

The moderate, intermittent, and usually painless, contrac- 
tions of the uterus, just alluded to, may in certain women of 
susceptible natures, and especially those of a rheumatic diathe- 
sis, give rise to pain, and constitute what are known as false 
pains. These we believe to be the exceptional, rather than the 
common cause of these painful sensations. False pains are 
usually irregular, often strong at first, but gradually becoming 
weaker; are limited in extent, rarely dilate the os or protrude 
the bag of waters, and are not generally accompanied by the 
muco-sanguineous discharge which usually precedes real labor. 
They arise chiefly from indigestion, cold, movements of the 
foetus, and various other causes, and are dispelled by remedies 
calculated to remove the causes on which they depend. False 
pains arising from hyperesthesia of the sensitive nerves and 
occasioned by the uterine contractions peculiar to pregnancy, 
are best relieved by caulophyllum. Pulsatilla, arnica, bryonia, 
and other remedies may be found useful. 

In a certain proportion of cases labor sets in abruptly, with 
severe and quickly-recurring pains, but as a rule the onset is 
gradual, and the pains are so far apart and so feeble that their 
real significance is not at first recognized. More painful con- 
tractions, however, soon ensue, creating restlessness, and 
causing all the phenomena peculiar to labor. Women greatly 
differ in their sensibility to pain, and the positions which they 
assume, and the movements which they make during labor are 



320 Laboe. 

correspondingly diverse. Some instinctively seek the bed and 
keep it throughout the parturient act, others prefer to sit or 
stand until the first stage is nearly finished, while others can 
scarcely be driven into a recumbent posture till the very close 
of the second stage. If sitting, the woman during the severe 
part of the first stage is usually disposed to throw the trunk 
of the body forwards as the pain comes on, resting her weight 
on the hands which press the thighs, or she bends backwards 
with the hands on the loins. The earlier pains rarely extort 
cries, but, when the os has reached a certain degree of dilata- 
tion, the suffering becomes so severe as to create great restless- 
ness and bring out some exclamations of distress. Occasionally 
the woman's fortitude is so great, or the pain so slight, that no 
sound of distress escapes her lips during either the first or 
second stage. 

True labor pains usually manifest their impression on the os 
uteri without much delay, and therefore labor may be said gener- 
ally to begin with the first indication of expansion or reduction 
of this part, provided there is evidence of strong, recurrent, 
coincident uterine effort. The expansion then begun progresses 
gradually— sometimes rapidly, until the entire cervical canal 
becomes large enough to admit of uterine evacuation. As the 
os internum opens, the contractions cause the membranes to 
descend and exert an expansive force on the cervical canal. 
During a pain the membranes become tense, and bulge through 
the opening to a greater or less degree, until, after a certain 
amount of expansion has been attained, they resemble the 
form of an old-fashioned watch crystal. This is true, however, 
only after the internal os has entirely yielded, and the edges of the 
external os have become thin from the pressure put upon them. 
As the pain subsides, the os relaxes and the membranes retreat. 
With the advance of labor, the pains increase in intensity, fre- 
quency and force, while uterine dilatation is usually progressive. 
Nausea and vomiting are not infrequent, and when present they 
add greatly to the woman's distress, though their effect on 
labor is often salutary. The softening, relaxation and hyper- 
secretion evinced in the soft structures, become more and more 
decided, and when the expansion has reached a certain limit, 
say a diameter of two and a-half or three inches, the protrud- 
ing membranes commonly rupture, and a considerable part of 
the liquor amnii escapes with a gush. Sometimes all the 
amniotic fluid escapes as shown by the sequence, but usually a 



Phenomena of Labor. 



321 



part of it is prevented from doing so by descent of the present- 
ing part, and is retained till final escape of the fcetus. 

The pulse increases in frequency in proportion to the severity 
of the pain, its acceleration being determined by the exercise of 
muscular energy. This effect on the circulatory apparatus 
may be usefully employed, some say, as a gauge of the efficiency 
of the pains, for, the more marked and uniform the variation, 
the more effective the contraction. "When, however," says 
Hohi, "the rapidity of the beats subsides before approaching 
the maximum, the pain is too weak; or when the rapidity rises 




Fig. 125. — Showing various stages of Dilatation. 
B, os internus. 



C, os tincse. 



by sudden starts, the pain is a hurried one, and in either case its 
effect will be imperfect." The pulse acceleration, under an 
efficient pain of average duration, he represents by the follow- 
ing record of the several quarters of two minutes : 18, 18, 20 r 
22: 24,24,22,18. 

This may all be true, but we have found the pulse of little 
value as a means of determining the efficiency of uterine action. 

The softening, relaxation, and hypersecretion become more 
and more decided. The blood found on the examining finger 
(21) 



322 



Labor. 



Uatrcreas 



Ooeliac A, 

Sup.Mcscrit/A 
V. Portai 




Bxetbri 



Ext. Oa Uie ri 



Rectum 



Liquor Amnii 



Fig. 126. — Section of a frozen body at the termination of the first stage of 
Labor. The membranes are still intact, the cervix is fully dilated, and the 
head, occupying the second position, is in the pelvic cavity. 



Phenomena of Labor. 



323 



and which tinges the mucus, proceeds mainly from the decidua 
and the uterine Avails with which it is in contact, since the 
former, owing to a gradual giving way of the os uteri, is being 
torn away from its maternal attachments. After a time, the 
head, influenced by uterine contractions, descends into the 
cervix, the walls of which are separated until they lie against 
the pelvic borders, and thereby form, with the uterine cavity 
and vagina, a continuous channel known as the parturient 
canal. This, the first stage of labor, varies greatly in duration 
but is generally completed in six or seven hours. It sometimes 
lasts but an hour, and on the other hand, it is occasionally 
protracted to one, two or three days. 




Fig. 127.— The Parturient Canal. 



The Mechanism of Dilatation.— It appears to be pretty 
generally conceded that the so-called bag of waters acts as a 
kind of entering wedge, by means of which an equitable hydro- 
static pressure is brought to bear in the direction of expansion, 
and that this is the mechanism through which dilatation of the 
os uteri is mainly effected. Leishman reasons learnedly and 
forcibly on the subject as follows : " The first efficient contrac- 
tion having resulted in an opening of the os to a trifling extent, 
and the tissues being sufficiently relaxed to admit of satis- 
factory progress, we are enabled to trace the process of dila- 
tation through all its subsequent stages. As soon as the os 



324 Labor. 

has yielded to a certain extent, the membranes which are here 
separated from their uterine attachment, commence to pro- 
trude in fche form, first of a watch-glass, and then of the 
extremity of a pouch or bag, which has been termed the "bag 
of waters." Following the operation of a very obvious law r 
already alluded to, this phenomenon implies, primarily, an 
attempt, consequent on the uterine contraction, on the part 
of the waters, to escape in the direction in which resistance is 
least. The special function, however, of this bag is to effect the 
further dilatation of the os, and we can conceive of no means 
which could be more admirably adapted to this object than the 
graduated fluid pressure which is thus brought to bear upon 
the os equally in its whole circumference. It constitutes, in 
fact, in its action during a pain, a hydro-dynamic force, which 
acts at once safely and powerfully upon the whole of the os." 

Theoretically this action of the bag of waters is very 
decided, but when we reflect upon all the conditions, we are led 
to doubt its practical effect. Moreover, every obstetric prac- 
titioner of much experience has surely observed that in many 
instances (we believe in at least thirty or forty per cent, of all 
cases) there is no well formed bag of waters, and, during a pain, 
but little fluid can be felt between the unbroken membranes and 
the head. In such labors hydrostatic dilative force is neces- 
sarily an unimportant factor. These cases, combined with 
those in which early rupture of the membranes takes place 
either spontaneously or artificially, rendered quite true 
Cazeaux's remark, — "In general, it (dilatation) is very slow in 
the commencement of labor, but much more rapid towards its 
close." This statement he in another place explains by saying, 
"The foetus evidently has no part in the dilatation of the os 
uteri until the bag of waters is ruptured. It is not until after 
this event takes place that the vertex, by engaging like a wedge 
in the uterine neck, can hasten the dilatation mechanically ; and 
it is equally evident that in any other than a vertex presenta- 
tion, the presenting part being more voluminous and irregular 
than the head, cannot perform the same office, and therefore, 
ceteris paribus, the orifice will open more slowly." 

But in those cases wherein a bag is felt, w T hat service does it 
render? This, of course, we are not able, even by the most 
careful experiment, to determine, since the conditions w T hich 
exist in labor cannot be artifically duplicated. In considering 
the question it must be borne in mind that the entire liquor 



Phenomena of Labor. 325 

• 
amnii is not available for the exertion of expansive force at the 
os, owing to firm pressure of the head, during uterine contrac- 
tion, against the pelvic brim and the soft tissues thereabout. 
This may be demonstrated by rupture of the membranes during 
a pain, even in instances of fully developed bags, the amniotic 
fluid confined below the head being the only part which then 
escapes. There are doubtless exceptions to this rule, as, for 
example, those instances in which the head does not descend 
forcibly against the lower uterine segment, and hence not 
against the pelvic brim, until after the first stage is consider- 
ably advanced. Another exception is found in those cases 
where pelvic deformity prevents a nice adaptation of foetal head 
to maternal parts. But in general we find upon rupture of the 
membranes during a pain, that the bag of waters, or rather that 
part of it within reach, empties itself, yet much of the amniotic 
fluid is left confined above the foetal head, and escapes in part 
by a continuous drain during the intervals of contraction, in 
part at the beginning of subsequent pains, but more especially 
after foetal expulsion. Resistance being withdrawn, the pre- 
senting part pushes down, and, "at the height of the contrac- 
tion," as Cazeaux says, "the flow is arrested because the direct 
application of the head against the orifice stops it completely." 
v 'After rupture," says Lusk, also, "which usually occurs sponta- 
neously, the water in front of the child's head escapes, though 
the greater part of the amniotic fluid is retained within the 
uterus by the valve-like pressure of the presenting part." We 
insist that these facts be borne in mind, and with them before 
us we will consider the theories of cervical dilatation usually 
advanced. 

"During the contraction," says Playfair, "the bag of mem- 
branes will be felt to bulge, to become tense from the downward 
pressure of the liquor amnii within it, and to protrude through 
the os if it be sufficiently open. The membranes with the con- 
tained liquor amnii, thus form a fluid wedge, which has a most 
important influence in dilating the os uteri. This does not, 
however, form the sole mechanism by which the os uteri is 
dilated, for it is also acted upon by the contractions of the 
muscular fibers of the uterus which tend to pull it open. It is 
probable that the muscular dilatation of the os is effected 
chiefly by the longitudinal fibers, which, as they shorten, act 
upon the os uteri, the part where there is least resistance." It 
is the fluid-w T edge action of the bag of waters to which has been 




326 Labqr. 

attributed such potency ; and, so far as it is related to early 
dilatation, we would not raise a dissenting voice. But after the 
os has attained a diameter of, say, two inches, the tumefied 
scalp and presenting occiput advantageously substitute it. A 
part of the liquor amnii having escaped, and a fair opening of 
the os having been secured, the uterus is enabled to act with 
force on the foetus, much as the fingers and thumb of the sur- 
geon would on the glans penis in retracting the foreskin for 
relief of phimosis. It will be understood that we do not reject 
the theory of hydrostatic aid in dilatation; but we do claim 

that experience and re- 
flection have led to the 
conviction that it per- 
forms a very unimpor- 
FlG 128 . tant part in the latter 

half of the process. 
It will then be asked, "Why are labors complicated by 
early rupture of the membranes more protracted and danger- 
ous than others?''* We reply that observers mistake in 
classing together all cases wherein rupture of the membranes 
takes place at any and every period before and during dilata- 
tion ; whereas a marked distinction ought to be made. When 
rupture takes place spontaneously before the first stage comes 
to a close, it most frequently occurs before the os has dilated 
to any extent, and while the woman is about the house or 
room, so that all, or nearly all, the amniotic fluid escapes, and 

the conditions thus 
become quite dif- 
ferent from those 
now being dis- 

cussed. We often 
Fig. 129. • 

rupture the bag of 

waters after a certain amount of dilatation has been accom- 
plished and have but a small amniotic gush, and yet the effect 
on labor is salutary. We are fully convinced that beneficial 
effects as often follow when there is not a redundancy of liquor 
amnii, as when there is. If dilatation goes on till the expan- 
sion acquires a diameter of about two inches before the bag of 
waters discharges, the delivery cannot be set down as a "dry 
birth," and it is not thereby rendered more difficult and dan- 
gerous, but, on the whole, less so. 

Dilatation of the os uteri is in the main dependent on other 





Phenomena of Labor. 327 

causes than hydrostatic pressure. "The process of dilatation 
of the os is dependent," we are told by Meadows, "according 
to the late Dr. Rugby, not merely on mechanical stretching 
which the pressure of the membranes and the presenting part 
exert upon it, bat also to the circular fibers being no longer 
able to maintain the state of contraction which they had pre- 
served during pregnancy ; they are overpowered by the longi- 
tudinal fibers of the uterus, which, by their contractions, pull 
open the os uteri in every direction." Cazeaux follows Desor- 
meaux in attributing dilatation of the os largely to action of 
the longitudinal 
fibers. Tyler 
Smith regarded 
the os as pos- 
sessed of both 
" dilatile and contractile " powers. He did not subscribe to the 
doctrine of equable and regular action of all parts of the 
uterus ; nor did he regard contraction of the body and fundus 
of the organ as any more capable of overpowering the circular 
fibers of the cervix, than are the respiratory muscles of forcing 
open the little glottis in case of spasmodic closure. Moreover, 
he assumed that the individual muscular fibers of the cervix do 
not continuously surround the part, for if they did they would 
be so stretched during passage of the foetus that they could 
never regain their contractility. He believed in a peculiar 
arrangement of the 
muscular fibers, by 
virtue of which 
something more 
than a sphincter is 
formed, attribut- 
ing to the cervix 
dilative powers. 

Though questioned by many, this dual action of the os cannot 
positively be denied. Indeed, from the spasmodic expansion of 
the unimpregnated os witnessed by Munde", and several others, 
during sexual orgasm, the part seems almost unquestionably 
to possess spontaneous dilative as well as contractive energy. 
The three main factors concerned in dilatation ot the part 
we would then set down as, (1) mechanical action, primarily, 
of the bag of waters, and, secondarily, and more energetically, 
of the foetal cranium or other presenting part; (2) contraction 




328 



Labor. 



of the longitudinal fibers of the womb; and (3) spontaneous 
expansive action of certain muscular fibers, not yet demon- 
strated, residing in or near the cervix. 

With respect to the first, it may be said that the bag of waters, 
in the early part of the first stage of labor, plays a very useful 
role by insinuating itself into the os, as shown in figure 128, and 
gradually spreading it, much as would a rubber dilator as ap- 
plied by the gynecologist. But long before expansion is com- 
plete this action loses its best effect (see figures 129 and 130) , 



/ i /'....'; It 






^^WimSS^I 




Fig. 132. — Section showing the Foetus, inclosed in its membranes, with 

expanding Os Uteri. 



and may be advantageously substituted by the scalp and cra- 
nium of the child, as suggestively shown in figure 133. 

Concerning the second, little need be said, since all admit 
the powerful effect of the strong longitudinal muscles of the 
uterus. The organ being thicker, and the muscular fibers more 
numerous, in the body, the weaker part is compelled gradually 
to yield, and thus, by degrees, expansion of the os is carried 
forward. 

Spasmodic contraction of even weak muscular fibers is 
hard to overcome and this sometimes seems especially true of 



Phenomena of Labor. 



329 



that involving the cervix uteri ; but, in a given case, when once 
it is broken, there may be not only cheerful acquiescence on the 
part of the muscular fibers involved, but efficient aid afforded 
by them or their congeners. 

Rupture of the Membranes. — After wide expansion of the 
os uteri and the way is open for foetal descent, pressure becomes 
so strong as usually to cause spontaneous rupture of the mem- 
branes. When unusually tough, they may, in neglected cases, 
continue unbroken, and envelop the foetus to the very close of 
the second stage. This can occur only when the placenta is 
dragged loose from its moorings, and is also extruded. A child 
thus enveloped is said to be born with a "caul." What is even 
more common, however, is a rupture of the membranes at the 
point where they surround the neck, and retention of the de- 
tached portion over the face, con- 
stituting a "veil," which old nurses 
regard as a sign of good luck. 

The Second, or Propulsive, 
Stage. — At this stage theos is com- 
pletely dilated, and somewhat re- 
tracted, so as scarcely to be felt. 
The uterus contracts more closely 
on the foetus and pushes it down- 
wards into the pelvic cavity. When 
it reaches this situation the woman 
begins to feel the presence of a 
solid body which must be expelled, 

and she accordingly bends every endeavor to the accomplish- 
ment of the undertaking. The pains assume a different char- 
acter. They are really much more painful, but the con- 
sciousness that they are accomplishing something seems 
to infuse both strength and courage. The powerful pro- 
pulsive efforts made by the woman are termed "bearing 
down," "propulsive," or "expulsive," hence the name, "pro- 
pulsive stage," often given to this part of labor. The 
resistance encountered in the first stage having been re- 
moved by the completion of dilatation, the pelvic brim, the 
varied relative diameters of the pelvic cavity, the pelvic floor, 
vagina and vulva, in turn resist rapid progress. When the 
pains are powerful, and resistance is great, tumefaction of the 
foetal scalp is likely to ensue at the point of least resistance, 
resulting in a swelling known as the "caput succedaneum.^ 




Fig. 133. 



330 



Labor. 



The recurring contractions cause the head to descend lower and 
lower, until it comes to press against and distend the perineum. 
The part advances during a pain, and recedes as the pain passes 
off, making a sensible gain each time. This to-and-fro move- 
ment is a wise provision of nature to prevent continuous pres- 
sure over any one pelvic area, as well as to obviate too rapid 



a. cooliac 
a.mes. sup. 



ventrio 



placenta 



orif. tub 



orif ut. int.< 



v. iLsin. 
- orif. ut. ink 




orif. ut. est. 

urethra — 1± 



vagina, 
rectum. 



Fig. 134.— The Uterus and Parturient Canal. (Foetus removed.) 



distension of the soft structures. The rectum becomes flat- 
tened and its contents expelled by the advancing head. 
Pressure on the pelvic floor, and subsequent distension of the 
vulva, open the anus to a considerable extent, and thin and 
elongate the perineum. As the foetal head enters the pelvic 
brim, with the occipital pole of its long diameter in advance, a 
condition of firm flexion of the chin on the sternum is enforced. 



Phenomena of Labor. 



331 



With the long diameter of the head lying in an oblique diameter 
of the pelvis, a movement in the pelvic cavity is necessitated, 
by means of which the long diameter of the vertex is brought 
into the conjugate of the outlet. This movement is termed 
rotation, and the time for its accomplishment is when the head 
presses firmly against the pelvic floor, and the perineum is there- 
by made to bulge The vulvar opening is put more and more on 
the stretch as the head emerges ; the woman gathers her ener- 
gies for every pain and presses as forcibly as her strength will 
allow; while now and then she gives vent to her terrible suffer- 
ings in an agonizing cry. The straining efforts of the woman 
are in a measure under her control. They are intensified by in- 




Fig. 135. — Distension of the Perineum. (Hunter.) 

flation of her lungs and forcible retention of her breath while 
she exerts them ; while, on the other hand, by opening the 
mouth and giving expression to her feelings in cries, the 
abdominal muscles are relaxed, and the straining efforts modi- 
fied. The head finally passes the vulva, and the woman 
experiences a sense of great relief, which is destined soon to be 
disturbed by a pain that brings the foetal body wholly into the 
world. Expulsion of the foetus is followed by an outpouring of 
the amniotic fluid, which is commonly reddened by blood from 
the vessels lacerated by decidual release and partial or com- 
plete separation of the placenta. The pains then cease, and 
the relief experienced by the woman is most delicious. It is the 
succeeding Heaven, the calm after the storm, the stillness after 
the upheaval, the rest after a wearying warfare with a relent- 



332 



Labor 



less opponent ; and but for it labor would be absolutely unen- 
durable. 

The duration of the second stage is exceedingly variable, be- 
ing largely dependent on the frequency and force of the pains, 
the form of the maternal pelvis, the condition of the soft 
structures and the size of the foetus. This stage of labor is 
occasionally completed in twenty or thirty minutes, though in 
many cases it lasts several hours, and but for interference would 
sometimes be prolonged indefinitely. 

Movements of the Pelvic Articulations. — There is a popu- 
lar notion among people of nearly all nations, and has been 
from time out of mind, that, during labor, there is exten- 
sive movement and separation of the pelvic bones. Many 
capable of forming an intelligent opinion on the subject, have 

cast much doubt on the claim that 
movement takes place at an articula- 
tion other than the sacro-coccygeal. 
The consensus of opinion, among the 
best authorities, appears to be that 
slight movement of the sort in ques- 
tion, does sometimes, if not uniformly, 
take place. At the symphysis pubis 
the ligaments are softened, and, under 
pressure, there is a little separation. 
At the sacro-iliac synchondroses simi- 
lar relaxation of ligamentous struct- 
ures occurs, the articular surfaces are 
sundered to a minute degree, and then there is performed an 
oscillation of the sacrum on its transverse axis. The sacro- 
sciatic ligaments share in the general relaxation, and thereby 
give greater freedom to the action. Zaglas was the first to 
call attention to the movement at the sacro- iliac articulation 
in other than parturient conditions. He found, for example, 
that in defecation, the oscillation amounted to about a line. 
Dr. Matthews Duncan describes a similar, but exaggerated, 
movement as taking place in the parturient woman, and indi- 
cates the advantages thereby afforded, and the conditions 
which favor it. Thus at the beginning of labor, as the head 
enters the brim, the woman instinctively prefers to sit, to walk, 
or, if to lie, to do so with the lower limbs extended, positions 
which favor the rotation backwards of the sacral base, and 
consequent increase of the conjugate diameter of the brim. 




Fig. 136. 



Phenomena of Labor. 333 

How often, in the early stage of labor, do we see the patient 
sit, during a pain, with her hands on her hips, and the 
shoulders thrown backwards. 

But when the head reaches the pelvic floor, and begins to en- 
gage the outlet, there is a manifest disposition of the woman to 
bend the body forwards, and flex the thighs, — conditions which 
favor extension of the conjugate diameter of the inferior strait 
by rotation of the sacrum on its transverse axis. 

The Third Stage. — The second stage merges into the third 
with full birth of the foetus ; and occasionally the third stage 
is terminated by the same contraction which ends the second. 
In general, the third stage is not brought to so speedy a close, 
but pursues a course marked by its own special phenomena. 
During this part of labor the intimate vascular relations be- 
tween mother and child are interrupted, and by orderly action 
of the natural forces the necessary changes are safely wrought. 

This stage of labor has its own peculiar dangers, which 
frown upon the woman more ominously than those of any 
other. It is sometimes ushered in by syncopal sensations, 
arising from recession of blood from the brain, occasioned 
partly by sudden withdrawal of intra-abdominal pressure, 
partly from blood-loss, but more especially, we believe, from 
general shock. This is usually short-lived, and the pulse be- 
comes firm and slow, showing high arterial tension. As reac- 
tion begins, the patient often experiences a chill, or, more 
properly speaking, a marked nervous tremor, the shaking 
being out of all proportion to the chilliness. This need cause 
no apprehension, since it proceeds from mere vaso-motor dis- 
turbance which speedily rights itself. A certain amount of 
blood-loss is characteristic of this stage, and may be regarded 
as salutary. In a plethoric woman it may be quite profuse 
without harm, while in another half the quantity would be a 
misfortune. In setting the normal bounds we are then carefully 
to consider the varying states of our patients. 

After the second stage, there is usually an interval of repose, 
of varying duration, before the uterus resumes its activity. 
This is succeeded by contractions of sufficient force to detach 
and expel the secundines. In unassisted cases the placenta 
may be expelled into the vagina, and there remain for an in- 
definite period. The contracting uterus follows the foetus during 
expulsion, and after extrusion of the afterbirth, condenses into 
a firm mass in the hypogastrium. Detachment of the placenta 



334 



Labor. 



takes place in the meshy, lamillated layer, which is formed in 
the serotina by the thinned, elongated walls of the gland tu- 
bules, the dense layer which forms the maternal portion remain- 
ing adherent to the placenta. 

Much emphasis has of late been put upon the mechanism of 
placental expulsion as elucidated by Dr. Matthews Duncan and 
others. It is held by them, — and their views are now generally 
accepted, — that when no traction is put upon the umbilical 
cord, the placenta issues from the uterus edgewise, though it 
may be folded longitudinally; but when it is drawn out by 





Fig. 137. — Normal mode of 
Separation and Expulsion of 
the Placenta. 



Fig. 138. — Mode of Separation 
and Expulsion when traction is 
made on the Cord. 



traction on the cord, inversion occurs, and, from the suction 
action thus imparted, the difficulties of delivery and the dan- 
gers of hemorrhage are augmented. 

Gassner found that after confinement, the female experiences, 
as a consequence of uterine evacuation, of exhalations from the 
lungs and skin, from the discharge of excrements, from loss of 
blood, and from other depletions, a loss of weight equivalent 
to one-ninth that of the entire body. 

Duration of Labor .—Labor differs so greatly in duration 
that it is almost impossible to deduce from observation any 



Phenomena of Labor. 335 

important facts concerning its length. It may be said, how- 
ever, that, in general, it is longer in primiparse than in multi- 
parse, on account of the greater firmness of the soft structures. 
It is also observed that, other things being equal, the pains and 
difficulties of first parturition increase with age. The relative 
depth of the pelvic cavity has a modifying influence upon labor, 
and accordingly it is found that very tall women pass through 
the ordeal with less facility than others. It is also true that 
short, stout women, with considerable adipose tissue, suf- 
fer long labors, owing to the firmness of their tissues, and the 
presence of an unusual quantity of fat in the pelvic cavity. 
The character of labor is subject to modification by the posi- 
tion and presentation of the foetus. Presentation of the face, 
for example, is attended with greater difficulty than that of the 
vertex, and an occipito-posterior position is more unfavorable 
than an occipito-anterior. Other modifying conditions are 
often found to exist, as the presence of tumors, contraction of 
the pelvic diameters, unusual size of the foetal head, etc. 

People are prone to think that it is within the power of the 
physician of skill and learning, to foretell the exact duration of 
labor, a thing, by the way, which he is not capable of doing. 
The pains may be vigorous, the tissues relaxed, and everything 
progressing in a satisfactory way, when the uterine contrac- 
tions may suddenly weaken, or utterly cease for many hours, 
or some other unfortunate occurrence interpose to interrupt 
the regular course of nature. 

The relative duration of the first and second stages is by 
some stated to be in the proportion of two or three to one, but 
others estimate it to be nearer four or five to one. In properly 
managed cases, the second stage is never longer than the first. 

The Hour of Labor.— The larger number of births is said 
to take place in the early morning hours. West observed that 
out of 2019 deliveries, 780 occurred between 11 p.m. and 7 
a.m.; 662 from 7 a.m. to 3 p.m. and 577 from 3 p.m. to 11 
p.m. Kleinwachter tells us that labor-pains usually set in 
between 10 and 12 p.m. Spiegelberg believes the maximum 
frequency of birth is between 12 and 3 o'clock. 

Lunar Influence on Parturition — Dr ; C. G. Eaue in 1865 
called attention to this subject, and reported his observations 
in thirty-four cases, in which, with a single exception, he found 
that birth took place at high tide. Dr. T. S. Hoyne found in 
seventy-five cases but four exceptions. 



336 Labor. 

Dr. M. M. Walker prepared a paper on the subject for the 
Horn. Med. Society of Penn. (Sept. 1882). with a report of 
two hundred cases, from which the following figures have been 
taken : 

Number born during solar and lunar flood tides combined, 42 

" solar flood, 52 

lunar flood, 38 

Total born during the flood tides, - 132, or 66 per cent. 

" " " " ebb tides, and at other times, 42, or 21 per cent. 

Instrumental cases and extractions, - - - - 26, or 13 per cent. 

Three cases born during the administration of an anesthetic, without 
instrumental aid, and included in the above table, occurred as follows : one 
during both solar and lunar flood, one during lunar flood, and one during 
ebb tide. These two hundred consecutive cases occurred from Nov. 1874 
to Aug. 1881. 



Management of Normal Labor. 337 

* 
CHAPTER III. 

THE MANAGEMENT OF NORMAL LABOR. 

Having given a brief account of the phenomena usually ob- 
served iu labor of a normal character, it becomes necessary to 
offer some observations on the management of the various 
stages of the parturient process. So wisely has nature adapted 
means to ends, that the act throughout is generally one which 
requires but little direction, and still less assistance, from the 
medical attendant. So true is this that we might add that, in 
the larger number of cases, as happy and satisfactory an issue 
results under the care of an uneducated, but experienced, at- 
tendant, as under the conduct of those highly learned, and 
consummately skilled. But irregularities in the parturient act 
are liable to arise, in the management of which mere experience 
will not avail. To meet and successfully manage complications 
as they arise, the accoucheur must have a thorough acquaint- 
ance with the phenomena of the normal process which haxe 
already been described, and be otherwise well grounded on 
obstetric principles. 

Preliminary Arrangements.— Within the scope of these 
suggestions regarding the management of labor, should be in- 
cluded mention of certain preliminaries, respecting which women 
often require some advice. In their proper place, observations 
respecting exercise and care of the bowels have been made, but 
we ought here to add that the woman should give especial 
attention to the observance of these. In no case should the 
customary stool be neglected when labor is at hand, and if 
there is the slightest tendency to constipation, as soon as pains 
are experienced a large enema should be taken and the bowels 
emptied, which will facilitate foetal expulsion, and at the same 
time render the necessary attentions of the accoucheur less 
disagreeable. 

Under the same head, we may call the physician's attention 
to the advisability of ever holding himself in readiness to 
attend midwifery cases, in order that no unnecessary delay 
may ensue. It is true that in the majority of instances there is 
no occasion for haste, but in many cases successful results are 
dependent mainly on the physician's promptitude in respond- 
ing to the urgent call. 

Prompt Response to Calls.— The practitioner will often be 

(22) 



338 Labor. 

subjected to the annoyance of being called before labor has 
actually begun, but this fact should make him none the less at- 
tentive and prompt. It is of the highest importance that 
abnormalities of foetal form, presentation, and position, and 
unfavorable maternal conditions, be recognized at the earliest 
possible moment, since this places the accoucheur in a position 
leisurely to determine upon a plan of treatment, to provide 
himself with the best facilities, and to choose the most desirable 
moment for interference. 

Armamentarium. — If the case to which he is called is likely 
to be difficult, the forceps and the perforator may be carried. 
Indeed, if the call is to take him a considerable distance from 
home, it is the part of prudence to take along such instruments 
as may be required in emergencies. The physician in active 
obstetrical practice will do well to provide himself with a bag 
or case of obstetrical instruments, which should include a good 
pair of long forceps, a perforator, a pair of craniotomy-forceps, 
a crotchet, a right-angled blunt hook, a decapitating hook, 
two or three vulvar retractors, four pairs of bullet forceps with 
catches, full-curved suture needles of various sizes, a needle- 
holder, catgut, silk, iodoform gauze, and a new soft rubber 
catheter. Besides these he should have a pocket-case of instru- 
ments, a hypodermic syringe, and a quantity of chloroform. 
He should provide himself also with a case containing, in 
addition to the most common homeopathic remedies, a reliable 
preparation of fluid extract of ergot. 

How to Approach the Patient. — There is no subject con- 
nected with midwifery practice, instruction concerning which 
would be more acceptable than this, and yet it is one upon 
which very little satisfactory instruction can be given. The 
fact is, that the etiquette of the lying-in chamber is founded 
upon the same general principles of deportment which govern 
the polite relations of life. Gentlemanly demeanor is about all 
that is required to insure mutually agreeable contact. Still, 
the caprices of women during labor are greatly augmented in 
number and volume, and the most considerate conduct on the 
part of the physician will sometimes be met with repulse. 

Women in parturition watch every movement, and mark every 
word of their medical attendant, so that his tact then, as per- 
haps at no other time, is put to a crucial test. Nor can their 
likes and dislikes, their opinions and their whims, be put into 
one general class and treated alike. Here, as elsewhere, to in- 



Management of Normal Labor. 339 

sure the best results one must individualize, and he who does 
so best, will achieve the most perfect results. 

The following advice, given by the erudite and urbane Dr. 
Blundell, is thoroughly practical and sensible: "If you are 
well known to your patient," he says, "on reaching the house 
you will be welcome to her apartment ; but if you have not fre- 
quently seen her before, nor attended her on former occasions, 
I would recommend you not immediately to pass into her 
chamber. Not having her full confidence, by your presence you 
might agitate her, and in these cases it is proper to avoid 
everything that may produce commotion of the nervous sys- 
tem. It is better, therefore, that the accoucheur retire into 
some adjoining room, where he may see his lady patroness, the 
nurse, who has generally a great many foolish things to say, 
all of which he may as well hear with patience and bon- 
homie. When the shower of words is blown over, or when 
Mrs. Speaker reluctantly pauses to draw breath, dexterously 
seizing the auspicious moment, you may make inquiries respect- 
ing; the progress of the labor, the condition of the bladder, the 
state of the bowels, and so on ; questions which, in ordinary 
cases, may with more delicacy be proposed to the nurse than 
to the patient herself. Should you chance not to be a dear 
man, a pious man, a good kind creature, or, still worse, should 
the lady be pettish, and declare you to be a brute or a physiol- 
ogist, so that for these manifold offenses she never, never will- 
never can see you — you may remain io the house, as the female 
'never' in these cases comprises but a small portion of 
eternity, perhaps on an average, some one or two hours, and 
when caprices and antipathies area little subdued by the pains, 
your presence will be cordially welcome. Now, then, the pains 
being severe, after you have entered the room, you may make 
your examination, and if you find the labor rapidly advancing, 
you must remain at the bedside lest the child should come into 
the world in your absence." 

The Examination.— When shall it be made? The stage of 
advancement which appears to have been reached, is the most 
determinate element. When the physician reaches his patient 
she may be experiencing the very first dilating pains, or she 
may already have progressed into the second or propulsive 
part of labor. In the latter instance, an examination cannot 
be made too soon, while in the former, there would be no oc- 
casion for haste. Unluckily, the existence of these various con- 



340 Labor. 

ditions cannot in every case be determined. It is possible, as a 
rule, to distinguish between the first and second stages of labor 
by external signs, as, for example, the peculiar pains of each ; 
but it does not follow that there is no urgency for an examina- 
tion because the os is not supposed to be wide open, nor that 
there is an inexorable and immediate demand for it because real 
propulsion has begun. The best counsel is, not to be so pre- 
cipitate in necessary investigations as to shock the patient, or 
betray trepidation; and on the contrary, not to permit undue 
caution or constraint to carry one to the opposite extreme; 
but to act deliberately and discriminately, keeping in mind the 
desirability of recognizing the important features of every case 
through a thorough vaginal examination, as early in labor as 
practicable. 

The finger is generally recommended to be introduced during 
a pain ; but it is far preferable to do so in the interval between 
pains, and to continue the examination during a contraction. 

The patient need not be restricted to any one position for 
the purpose of examination. Women are extremely restless 
during labor, and in frequent changes seek relief. They assume 
all sorts of postures, and resort to all kinds of expedients, and 
one must deal in an accommodating way. Let the woman re- 
main undisturbed by any considerable change, and she will 
evince less aversion to the necessary touch. The allusion is 
now to cases as they are ordinarily met. When for operative 
purposes, an absolute diagnosis of the exact presentation and 
position, and the condition of the parturient canal in obscure 
cases, becomes essential, the position most favorable for dif- 
ferential distinctions should be prescribed. This is generally 
upon the back, near the edge of the bed, so as to permit the 
use, with equal facility, of either hand. Sometimes the os uteri 
and presenting part are more easily reached when the decubitus 
is lateral. 

Cursory examinations are of little value. In the practice of 
obstetrics, as well as in all other affairs, "what is worth doing 
at all, is worth doing well." None of us possess supernatural 
powers, and therefore ought not to assume celestial airs. It 
takes time to make a thorough exploration. 

Nothing is more annoying to a woman of delicate sense than 
a bungling attempt to pass the finger. A hint worth remem- 
bering is that the vaginal orifice lies but slightly in front of a 
line from one ischial tuberosity to the other. Whether the 



Management of Normal Labor. 



341 



woman lie on her side, or on her back, the hand may be passed 
in a careless manner against the tuber to locate it, and thus 
ensure proper direction to the fingers. 

The points to be observed in a careful examination are the 
conditions of the vulva, bladder, rectum and vagina ; the size 
and relative state of the os and cervix uteri; the general loca- 
tion of the presenting part, its character and position; the 
condition of bhe foetal membranes, and the general capacity of 
the pelvis, at the brim, in the cavity, and at the outlet. 

Frequent examinations should be avoided, as they tend to 
irritate the vulva, and cause the woman, if sensitive, unneces- 
sary suffering. Yet, no matter how painful they may be, they 
should be made of- 



ten enough to ac- 
quaint the physi- 
cian with the pro- 
gress being made. 
A single finger may 
answer, but two 
fingers, should, as 
a rule, be employed. 
In every instance 
they should be 
smeared with some 
bland lubricant be- 
fore introduction. 
External Ex- 
amination.— Examination of the abdomen by palpation should 
not be omitted, and if there be a serious doubt concerning the 
presentation, the existence of single pregnancy, or the pres- 
ence of fcetal life, auscultation should be practiced. A super- 
ficial manual examination of the abdomen, rapidly made 
under the clothes, is a common practice; but it is advisa- 
ble to go further and make a systematic, scientific and ac- 
curate manipulation, by which we may ascertain the existence 
of pregnancy, the fcetal position, presentation, approximate 
size and general condition, and the relations of the uterus. 
Concurring heartily in what Hoist says on the subject of bi- 
manual examinations, that "a detailed discussion of this 
method of examination is necessary to the completeness of a 
text-book," we have elsewhere considered the subject at some 
length. 




Fig. 139.— The Vaginal Touch. 



342 Labor. 

Has Labor Begun?— As a rule, when the physician is called, 
there is no doubt that labor has begun. Often he is not sum- 
moned till the middle of the process, and upon examination 
finds the os uteri open, the liquor amnii discharged, and the 
head of the foetus approximating the outlet. In other cases, 
however, the presence of what have been described as false 
labor-pains, leads the woman to believe that parturition has 
made some progress, when in reality it has not begun. Careful 
attention to a few clinical hints will confer the knowledge and 
acumen necessary to differentiate the real signs of labor. With 
the finger in the vagina during a pain, observe whether there is 
any descent of the presenting part, or distension of the bag of 
waters, or other symptoms of forcible uterine contractions. 
Observe further, as the pains come and go, whether there is 
progressive uterine dilatation. Mere openness of the os uteri 
is not conclusive evidence. There is a difference between real 
dilatation of the os, such as comes from incipient labor, and 
an open state of the part. For weeks prior to delivery there is, 
sometimes expansion to the size of a quarter of a dollar, or 
even more. An increasing expansion of the os uteri denotes 
the existence of real parturition. The three decisive indications 
of labor are, then, (1) advance and retreat of the presenting 
part; (2) tension and relaxation of the membranes; and (3) 
above all, progressive expansion of the os uteri. 

Other, less decisive, indications of labor are an open and 
relaxed state of the vulva, accompanied with a more or less 
free flow of mucus, or mucus and blood, and rhythmical pains 
returning every ten, fifteen, twenty or thirty minutes. 

False Labor-pains. — Women, as they approach the close 
of utero-gestation, often suffer with pains which simulate, in a 
measure, those of labor. Believing that real travail has begun, 
they summon the physician to their bedside, to whose annoy- 
ance an investigation develops no substantial evidence of 
incipient parturition. "False alarms" of this kind are by no 
means infrequent, and are sometimes repeated by the same 
woman. 

The Symptoms of false labor-pains vary to correspond with 
the causes whereon they depend. The pain is often located in 
the umbilical region, and is clearly referable to the enlarged 
uterus. The ovarian region is sometimes its seat, and again it 
is felt in the hypogastrium, in which case it most closely simu- 
lates the pains of real labor. Finally, it is occasionally felt 



Management of Noemal Labor. 343 

most severely in the lumbo-sacral articulation, and extends 
downwards into the thighs. 

False labor-pains are, as a rule, continuous, but may present 
exacerbations. In some instances they are intermittent, but 
irregular in recurrence, while occasionally they come and go 
with the rhythmus of true pains. 

Causes. — Spurious labor-pains owe their origin to a variety 
of causes. Undue distension of the uterus and abdomen can be 
set down as one of them. This may operate in a two-fold 
manner. 1. The very distension may create a bearing, tensive 
feeling in the pelvic region, especially in the latter half of the 
ninth month, w T hen there is usually more or less subsidence of 
the organ; 2. The normal contractions of the uterus which 
regularly recur throughout the greater part of pregnancy, may 
become painful as a result of the great tissue-strain which 
exists. 

Apart from unusual distension, there is, in the few days which 
precede labor, great pressure downwards of the gravid organ, 
which is capable of creating not only vesical and rectal irrita- 
tion, but a certain amount of real pain. 

Women of delicate organization, and those whose strength 
has been impaired by disease, are liable to suffer from neuralgia 
affecting the pelvic and abdominal viscera. Pains of this char- 
acter are often intense, and sometimes observe a degree of regu- 
larity in recurrence. 

In some cases, what are termed false labor-pains may be due 
to rheumatism, though probably it is not a common cause. 
The uterus being rendered exquisitely sensitive by its rheumatic 
or rheumatoid state, cannot painlessly undergo the distension, 
the pressure, and the slight contraction, to which it is physio- 
logically subject. 

Yery likely false labor-pains are frequently excited by reflex 
causes. Irritation exists at some point, — commonly the 
stomach or bowels,— and is reflected to the uterine region, 
giving rise to suffering resembling that of incipient parturi- 
tion. 

Diagnosis.— The physician ought to be able to discriminate 
with exactitude between the genuine and the spurious, as he 
may thereby protect his professional credit, and save his pa- 
tient an unnecessary amount of distress. Keputable and gen- 
erally competent physicians, have been victims of error in such 
cases. A correct diagnosis is not always made with facility. 



344 



Labor. 



Single symptoms are not decisive : a sound opinion must rest 
on the totality of signs. 

Perspicuity in differentiation between spurious and genuine 
labor-pains is best attainable by a close comparison like that 
which follows : 



TRUE. 

1. Most frequently felt in lumbo- 
sacral and hypogastric regions. 



2. Pains rarely constant 

3. Pains always recur with regu- 
larity. 

4. Pains quite uniform in dura- 
tion. 

5. Pains at first far apart, and fee- 
ble, gradually becoming more fre- 
quent and severe. 

6. Pains generally preceded or 
accompanied by a mucous, or muco- 
sanguinolent discharge from the 
vagina. 

7. The internal os is found to have 
yielded partially, or fully, and the 
cervical body to have disappeared. 

8. The uterus during a pain con- 
tracts with force, and the mem- 
branes bulge. 

9. The os uteri is found to be di- 
lating. 



FALSE. 

1. Sometimes felt in lumbo-sacral 
and hypogastric regions; occasion- 
ally in inguinal, but oftenest in um- 
bilical region. 

2. Pains often constant, sometimes 
remittent, but rarely intermittent. 

3. Pains generally irregular. 

4. Pains generally very unequal 
in duration. 

5. Pains continuous, remittent, or 
intermittent with short intervals, 
their intensity observing no regular 
increase. 

6. Pains occasionally accompanied 
by a mucous discharge from the 
vagina. 

7. The internal os sometimes 
found closed, and the cervix distinct. 

8. There may be uterine contrac- 
tion, but it is not forcible, and the 
membranes, if they can be felt, are 
but slightly, or not at all, affected. 

9. The os is not dilating, though 
occasionally it is somewhat patulous. 



Treatment. — If the pains are severe, the woman ought to be 
placed in the recumbent posture, in a quiet room, and every 
annoyance attentively removed. Search may then be made to 
ascertain if the pain is not reflected from some distant point, 
and if such a cause is found, it must, if possible, be removed. 

Local treatment will afford much relief, especially in rheu- 
matic and neuralgic cases. Haniamelis or warm spirits may be 
freely applied to the abdomen. Unctuous applications will 
greatly relieve the feeling of over-distension, and consequent 
suffering. 

When the pains observe a decided periodicity, like those of 
labor, canlophyllum in a low potency is very effectual in many 






Management of Normal Labor. 345 

cases. Some physicians regard it as a real specific. When there 
is spasmodic pain, or when the woman suffers in the ovarian 
region, especially at night, and is restless and uneasy, Pulsa- 
tilla should be given. Actsea racemosa is peculiarly serviceable 
in rheumatic or rheumatoid conditions. Belladonna, and its 
active principle atropia, are especially suited to the pains when 
of a neuralgic character. Nux moschata: spasmodic, irregular 
pains ; the patient has drowsy, faint spells. Nux vomica may 
be required when the pains seem to depend on gastric irritation. 
Arsenicum album: when there is gastric irritation and thirst; 
the pains are sharp and distressing. 

The Patient's Bed and Dress.— These are matters with 
which the physician generally has little to do, as they properly 
belong to the nurse or other female attendants. It is wise, how- 
ever, for the physician to be prepared to supervise them, when, 
in emergencies, he is appealed to. The bed should not be very 
soft ; — the best is a good hair mattress upon a tick filled with 
straw or husks. A soft rubber or oil cloth should be laid over 
the mattress, and a sheet spread upon it. A folded sheet, or a 
wood-wool pad, should also be placed under the woman's hips, 
and another sheet should be pinned about the hips, the chemise 
and nightdress having been rolled up, for protection. During 
labor the amount of covering may be regulated to suit the 
patient's wishes, unnecessary exposure being avoided. 

The lying-in chamber should be as large and airy as the 
house affords, and provided with good facilities for heating if 
the labor occur in a cool season. 

Position of the Woman. — If the room is warm, there is no 
valid objection to the patient walking or sitting as her inclina- 
tion may suggest, in the early part of labor; but this should 
not be permitted after the second stage is fairly inaugurated. 
She ought then to be confined to her bed. When the presenting 
part has descended low into the pelvic cavity, and the pains are 
strong, on no account should she be permitted to rise. The 
compression exerted by the head, or other presenting part, may 
create a tenesmus of both bladder and rectum, and frantic 
requests be made for the privilege of using the chamber-vessel. 
This, however, should not be permitted, for fear of a sudden 
termination of the expulsive act while the woman occupies an 
attitude unsuitable for proper protection of mother and child. 

The Physician's Attendance During the First Stage. — 
During the first stage of labor the physician ought not to be in 



346 Labor. 

constant and close attendance, as such attention would raise 
too high the woman's expectations of speedy delivery. The 
physician himself will find frequent, and somewhat prolonged, 
absence from the room a grateful relief from the oft-repeated 
query of both the patient and her friends regarding the dura- 
tion of labor. To give non-committal, and yet satisfactory 
answers, is no easy task. His absence, too, will give the woman 
time and opportunity to use the chamber-vessel, or visit the 
closet, a thing which she should be encouraged often to do dur- 
ing this stage. If at any time there should be evidence of much 
urinary accumulation, with inability to empty the bladder in a 
natural way, the catheter ought to be employed. 

Bearing Down. — Women are generally encouraged by the 
nurse, and other bystanders, to bear down with force whenever 
a pain returns ; but in the first stage of labor this should be 
utterly discouraged. The practice is not only useless, but 
harmful. In the second stage only can much aid be derived 
from abdominal efforts, and earlier exertion tends needlessly to 
exhaust the patient's strength. 

Treatment of the Membranes. — Upon making a vaginal 
examination after labor has fairly begun, there is often, but not 
always, to be felt protruding into the os uteri during a pain, a 
tense disk of membranes termed the bag of waters, or the bag 
of membranes. It is the practice of some to break this bag, 
and allow the liquor amnii to escape, early in labor, under the 
belief that progress is thereby accelerated ; but the most 
approved treatment is to refrain from so doing until full dila- 
tation of the os has been accomplished. The latter conduct is 
generally recommended on the theory that the bag of waters, 
by the hydrostatic force which it exerts, aids very materially 
in the process of dilatation. It is found, however, that, in a 
large percentage of cases, there is no distinct bag of waters at 
the os uteri, and yet dilatation proceeds in just as satisfactory 
a manner. Again, in certain cases wherein the phenomena of 
the first stage are slowly and tediously manifested, rupture of 
the membranes will often greatly accelerate the natural pro- 
cesses. Still, we will probably do well to adhere, as a practice, 
to the old rule, and refrain from rupturing the membranes until 
the stage of uterine dilatation has been completed. The bag of 
waters can be ruptured more easily during a pain, at which time 
the membranes become tense; and if it cannot be effected with 
the finger, a probe, or a stiff catheter should be carefully used. 



Management of Normal Labor. 347 

The Second Stage.— Thus far we have treated mainly of 
the duties of the accoucheur during the first stage of labor. 
But with comjjlete dilatation of the os uteri the first stage 
closes, and is succeeded by the second, or propulsive, stage. 
The precise moment of complete dilatation is not always easily 
recognized. Indeed, there appears to be some dissonance of 
opinion with reference to what constitutes full dilatation. We 
are left to infer from most descriptions that complete expansion 
is not accomplished until the os has passed out of reach of the 
examining finger. What we have to say here with reference to 
the management of the second stage of labor is fully applicable, 
however, to a period which somewhat precedes entire retraction 
of the os uteri. For practical purposes, then, we may regard 
the first stage of labor fairly closed when the os is widely 
expanded, and the presenting part, proper, and not alone the 
caput succedaneum, protrudes, during a pain, to a certain 
extent, through the os uteri. 

Encourage Bearing Efforts. — The phenomena of the sec- 
ond stage are distinct and peculiar. The woman is now dis- 
posed to bring into action her abdominal muscles, and with 
each severe pain to make a strong bearing effort. This action, 
unless vehement beyond measure, ought to be encouraged, and 
every facility afforded for its proper direction and utilization. 
While she occupies the dorsal position, the physician may sit 
beside the bed, or upon it, and hold one hand of his patient, 
while someone on the opposite side holds the other. The feet 
may be braced against the foot-board directly, or through the 
intervention of a stool, box, or chair; or, what will answer as 
well, the woman's knees may press against the shoulders of her 
assistants. Now, by encouraging her to close her mouth, to 
hold her breath, and to pull and bear down, very effective 
work may be done. When the patient lies on her side, both 
hands may be held by an assistant, while the knees rest against 
the latter's body for a fixed support. Such counter-traction 
requires the services of a strong person. Between pains the 
woman should be permitted to take perfect rest. If descent 
proceeds rapidly, the fingers of the accoucheur should be kept 
within the vagina, and the case carefully watched ; but if slow 
progress is made, an occasional examination only, is, for a 
time, required. 

The pains of the second stage are in some respects more sat- 
isfactory to the patient, than those of the first stage, inasmuch 



348 Labor. 

as they appear to be more effective ; but the real suffering ex- 
perienced in this part of labor is far more intense. The woman 
becomes restless and impatient, and makes frequent inquiry as 
to how soon labor will terminate, at the same time declaring 
that she can endure the suffering no longer. Great tact is here 
required to maintain the patient's courage and confidence. The 
manifestation of the slightest perturbation by the physician is 
liable to create a panic among the patient and her friends. Few 
words, fitly chosen, spoken with evident composure, are far 
better than long explanations, or much talk on any pretext 
whatever. 

The Use of Anesthetics.— The general subject of anes- 
thesia during labor will elsewhere be discussed, but we may 
here take occasion to say that, in the latter part of the propul- 
sive stage, when the pains become almost unbearable, there is 
no well-founded objection to be raised against the moderate use 
of chloroform. A few drops ma} 7 be poured on a handkerchief, 
and when a pain is due, the woman may take a few inhalations, 
with the effect to somewhat benumb the sensibilities without 
producing narcotism. Such administration of a good article of 
chloroform is almost wholly devoid of danger, and may be con- 
tinued for several hours, if needed. A little instruction given 
the nurse will enable her safely to use the anesthetic, to the ex- 
tent mentioned. The severity of pain suffered by women in 
labor varies so considerably that chloroform should not be re- 
sorted to indiscriminately; but let it be given in those cases 
only wherein there is a strong demand for its soothing aid. 

Indications for Interference. — So long as there is progress 
being made, we should abstain from interference. If the pains 
slacken, or if delay of the head in the pelvic cavity arise from 
any other cause, we should not allow the duration of the second 
stage to exceed physiological limits. A satisfactory defini- 
tion of what is implied by the phrase ''physiological limits" 
cannot be easily given, since its boundaries are not fixed, and 
they require to be set in each individual case. It should be re- 
membered that pressure of the head upon the soft tissues of 
the pelvic cavity, leads, when prolonged, to pathological changes 
in the tissues of the canal and outlet. It is a wise rule of prac- 
tice not to permit the head of a relatively large child to remain 
stationary in the pelvic cavity for a period in excess of two 
hours. But before resorting to instrumental delivery, the aid 
of other means should be invoked. 



Management of Normal Labor. 



349 



Feeble pains are sometimes intensified by changing the 
woman's position, as from the back to the side, or vice versa. 
Firmer flexion of the foetal head is sometimes thereby effected. 
When that part has descended to the perineum, expulsive action 
may be excited by kneading the abdomen, or by pressing upon 
the fundus uteri. 

Use of the Catheter. — There is sometimes considerable dis- 
tension of the bladder during the second stage, accompanied 
with utter inability to urinate. This distressing condition 
must at once be removed by means of the catheter. The use of 
the instrument is sometimes attended with considerable diffi- 
culty, owing to pressure of the head against the neck of the 
bladder, and a change in the direction of the urethra, arising 
from excessive compression and partial prolapse of the anterior 
vaginal tissues. On these accounts the best instrument for use 
is the soft rubber catheter of medium size. 

Incarceration of the Anterior Lip of the Os Uteri.— As 
the head descends into the pelvis, the anterior lip of the os uteri 
is sometimes caught and held between the head and the pubis, 
and may thereby become a manifest impediment to the progress 
of labor. Unless there is excessive tumefaction of the part, in- 
terference is seldom required. Rigby declares all attempts to 
push it above the pelvic brim not only futile, but decidedly 
objectionable, since inflammation is liable to be set up. This 
dictum is not accepted by all. ''Any attempt," saysLeishman, 
"rudely or forcibly, to push up the anterior lip, even when it 
exists as a manifest impediment, should certainly be avoided ; 
but we are bound to add that, in many cases, it may be pushed 
beyond the head with perfect safety, and in this way the im- 
pediment to delivery may be at once obviated." The attempt 
should be made in an interval between pains, and the part sus- 
tained until the recurrence of another contraction serves to 
maintain it in a situation above the limit of compression. 

The Prevention of Vulvar Laceration.— Owing to the 
form and direction of the parturient canal, following as it does 
an irregular curve, the structures in that part of the curve 
which is least in accord with the uterine axis, and hence 
farthest from the line of propulsive energy, receive the brunt of 
the force, and are compelled to make the chief resistance. The 
included angle of the two sides represented by the line of pelvic 
entrance and the vulvar plane upon which the foetus finally 
emerges, is practically a right angle, and hence the Delvic floor 



350 Labor. 

is obliged to meet the descending head and deflect it in the 
direction of least resistance, at the expense of considerable 
strain. It follows that the question of laceration of these 
structures is very largely determined by their strength and 
elasticity. 

We do not need to make many examinations to learn that 
there is a vast difference between perinea. Some are large and 
thick and strong, while others are small and thin and weak. 
The former can resist a powerful strain, while the latter are 
capable of withstanding but little. Pass your finger during 
labor along the vaginal surface of the perineum and pinch 
that body between the thumb and finger. 

In one case you find it thick and firm, but moderately long 
as measured from the vulva to the anus, and evidently able to 
bear, without breaking, all the power which is likely to be 
applied from above. Again you find a long, thin, moderately 
muscular structure, comparatively yielding, and clearly unable 
to turn aside a body propelled against it with much force. In 
a third instance you find almost an entire absence of perineum, 
the recto-vaginal septum being but slightly thickened below, so 
that a shallow laceration would extend to the rectum. In a 
case like the first we have seen the head press firmly down on 
the pelvic floor, the perineum resolutely resisting the strain for 
a considerable time, and finally turning the descending head 
aside and causing it to glide forwards through the vulva, whence 
it escaped without harm to the soft structures of this part, the 
integrity of which is so essential to the health of the generative 
organs. In cases like the second we have seen the long, thin 
perineum yield under much less strain, splitting to the very 
margin of the anus. Lastly, in a case like the third, we have 
seen the deficient perineum left after delivery still more deficient 
than ever. 

Danger of laceration is much augmented by unusual length 
of the parturient canal below the bony outlet. During descent 
of the advancing head the soft tissues are pushed more or less 
in advance, and the greater distance required to be made by the 
head, and hence the more extensive the curve, the greater the 
danger to the perineum. This truth is to be borne in mind 
during our consideration of the proper measures to be adopted 
for protection of the vulvar structures, and above all in our 
conduct of labor complicated by such a condition. 

At the moment of greatest distension, the very margin of 



Management of Normal Labor. 351 

the perineum at the posterior commissure is nearly always thin, 
and it is evident that a rent once started is liable to become 
extensive. We are speaking now of cases left substantially to 
the natural movements. When a rent is begun it draws the 
head away from the anterior boundaries, or, more properly 
speaking, diminishes the pressure against the crown of the 
pubic arch, with a resulting extension of the laceration beyond 
the degree essential to easy escape of the head. This is a 
natural result of neglect on the part of the accoucheur to 
enforce the true principles of perineal protection about to be 
enunciated. 

Those who carefully examine the perineum during the 
moment of greatest distension have frequently observed that 
there is usually a thin margin extending backwards only a 
limited distance, and then the examining finger comes upon a 
thick, firm, strong part, which appears to be the perineum 
proper. This thin portion is made up chiefly of integument 
and mucous membrane, while the thick part is composed largely 
of muscular tissue. This is a favorable condition of things to 
find, but it does not exist in every case, and where it is absent, 
in a primipara, we ought to be on the alert. When it does 
exist, laceration, if it takes place at all, is likely to be limited 
to the anterior thin part of the perineum, exceptionally 
extending into the muscular structures. In these cases the 
thick part of the perineal body serves as a boundary to the 
tear, casting the pressure back on the pubic arch which it had 
begun rapidly to leave. 

We are not among those who ascribe vulvar laceration ex- 
clusively either to the head or to the shoulders, nor are we dis- 
posed to unite with some in ascribing the accident more 
frequently to the shoulders than to the head. Still we are quite 
willing to admit that the perineum is often torn during passage 
of the trunk of the child. Obstetricians are quite accustomed 
to say that the trunk can follow wherever the head can go, and 
as a rule, so it can. Yet we have seen the head pass without 
injury to the perineum, and a laceration result from pressure 
of the fcetal elbow as it slipped through the vulva. We are 
well convinced that more injuries to the perineum and vestibule 
occur during passage of the head than of any other part ; but 
next in frequency stand the foetal elbows. The shoulders them- 
selves rarely cause the accident. When the elbow of the child 
comes over the distended perineum, as it often does, with a 



352 Labor. 

jerk, the structures which had previously resisted most heroic- 
ally may finally give way. 

The conditions which promote solution of continuity at the, 
vulva are more especially met in the primipara. The intact 
fourchette, the narrow vagina and the resisting tissues are all 
of this nature. When once the vulvar orifice has been thor- 
oughly distended, it yields more readily a second time. More- 
over, though these structures are decidedly elastic, after 
thorough distension they never wholly regain their former 
tenseness. It therefore follows that we look for laceration 
mainly among women for the first time in labor. Still it does 
occasionally happen that the first child is premature, and 
hence small, while the second is of full term and much larger. 
Again, a former laceration may have been repaired, and the 
conditions met in a second or third labor prove as inimical to 
the perineum as those in the first. 

It should be remembered that the vulva may suffer anteri- 
orly as well as posteriorly. As the head emerges from the 
vulva, the vestibule can be felt with its thin, tense margin 
turned towards the head, ready to tear should much further 
strain be put upon it. This region is a common seat of injury. 
A laceration in this part usually passes to one side of the 
meatus urinarius, and when present is liable to make urination 
somewhat difficult, and, occasionally, impossible. This is a 
more common cause of retention of urine after delivery than 
reflex spasm excited by lacerated perineum. 

The anatomical conditions being such as we have described, 
it is plain that rapid descent of the head and sudden pushing 
asunder of the contiguous structures, with forcible distension 
of the vulvar opening, are more likely to result in laceration of 
the parts involved than a dilatory accomplishment of the same 
parturient act. Here, as elsewhere, haste makes waste. Rapid 
changes in the human organism are accomplished at unusual 
risk. Nature's plan is the gradual one. The whole body can 
be broken down and renewed without pain or disturbance if the 
work be done by degrees. Cyclonic movements are destructive. 

When the perineum is unusually long and comparatively 
yielding, it is subject to great danger, no matter whether pro- 
tective measures be adopted or not. Cases have been put on 
record wherein the descending head has steadily pressed on its 
center to such a degree and for so long a time, that finally a 
false opening has been created through which the foetus has 



Management of Normal Labor. 



353 



emerged without rupture of either the posterior vaginal com- 
missure or the sphincter ani. To be sure this is a singular ac- 
cident, and fortunately rare. There is a form of laceration in 
such a perineum, however, worthy of special notice, of which 
I have recently had two or three marked examples, and which 
is doubtless of great frequency. It is not discovered through 
mere touch except in bad examples of it, and does not disclose 
itself to mere inspection unless the same be carefully made. 
Externally there may be no sign of injury, but upon retracting 
the perineum and opening the labia, we find the lesion in the 
form of a superficial rent along the vaginal surface of the 
perineum, occasioned probably by the head as it pushed heav- 
ily along on its way to the vulva. Though of but slight depth, 




Figs. 140, 141 and 142.— Showing the difference in involved diameters 
between Flexion and Extension of the Head. 

it may be found, on lateral traction, to gape more than an inch. 
Such a laceration is not likely to be felt very profoundly in the 
way of weakening the natural supports of the pelvic viscera ; 
but it acquires importance by reason of its favorable situation 
for taking up septic matter during the puerperal stage. 

Now all these dangers are still further augmented by failure 
of the head, in its descent through the pelvis, to maintain its 
position of firm flexion in vertex presentation, or firm exten- 
sion in face presentation. When such proper relations of the 
advancing head to the pelvis are not maintained, the longest 
diameter of the head, namely, the occipito-menta.1, is liable to 
be thrown into one of the pelvic diameters ; and since the former 
is greater than the latter, the head is likely to become incarcer- 

(23) 



■H 



354 Labor. 

ated and instrumental interference be required. Mere use of the 
forceps does not necessarily increase the perineal dangers, but 
the delay at that particular point, and final rectification 
through forcible flexion, followed by instrumental delivery, does 
militate against perineal integrity. But the head is far more 
frequently thrown out of proper position to a moderate degree 
only, in which case, though incarceration may not ensue, un- 
usual demands will be made on the pelvic outlet, and the vulva 
in this way come to suffer. This anomalous condition of things 
thus becomes a prominent factor in the production of perineal 
laceration . 

These are the main facts relative to causation of perineal 
rupture, plainly, but not nicely put ; and now let us turn to a 
consideration of the prophylaxis of the accident. The original 
method of managing the head and shoulders as they passed 
the pelvic outlet was doubtless the expectant one, and some 
still adhere to it. "Hands off," they say, "and you will get 
better results than are obtained when attempts are made 
at prevention." When manual aid became the practice, 
it was almost the universal custom to "support the peri- 
neum." This treatment was based on right principles, but 
was probably carried to unnecessary and harmful extremes. 
At any rate, there was a reaction from it, so that now a num- 
ber of the best obstetricians practice the let-alone method. Ke- 
flex action is originated, they say, and the uterus is thereby 
excited to more energetic contraction, at the very time when 
modified action is sought. Of this we are not fully convinced ; 
and, while we may not commend the more ancient method, we 
are fully convinced that, properly used, some form of perineal 
protection is far better than the expectant plan. 

Before we enter upon a discussion of the various methods of 
protection now in vogue, let us deduce the general principles 
upon which any form of perineal protection, in order to com- 
mend itself to the enlightened judgment of a practical obste- 
trician, should rest. If we once get a clear conception of these, 
we shall have little trouble in adapting different methods to 
varying circumstances. The true principles of perineal pro- 
tection are four in number, as follows : 

1. Prevention of too rapid progress of the head and after- 
coming shoulders. 

2. Maintenance of firm flexion of the head in vertex pre- 
sentation and firm extension in face presentation. 



Management of Normal Labor. 355 

3. Deflection of the head from its movement of direct 
descent, causing it to hug the pubic arch ; and 

4. Kelaxation of the vulvar structures so that the necessary 
dilatation may be obtained without too great strain on the soft 
tissues. 

The first may be accomplished by independent manoeuvers, 
such as plain pressure against the head as it is forced down- 
wards by recurring uterine action ; but it is much better to 
combine this with such measures as will carry into effect also 
one or more of the other principles. The necessity for this re- 
sistance is at the pelvic outlet only, where there is likewise a 
demand for practice of the other principles. But better than 
all resistance is a wise modification of the propulsive energy, 
which may in a measure be accomplished by directions given 
the woman herself. Uterine action is not, but abdominal ac- 
tion is, in a measure, voluntary. Under command of the will, 
abdominal action is often surprisingly powerful. To completely 
overcome it through an effort of the will is utterly impossible, 
but much can be done by enjoining voluntary propulsive effort 
and bidding the woman give vent to her agony in cries, while 
regularity of breathing should be maintained as far as possible. 
These measures alone may suffice, but in some cases it is advis- 
able to administer chloroform till the rigor of the contractions 
is broken and the head is thus brought under control. 

There are two, and only two, methods of protection for the 
perineum at the moment of greatest distension worthy of the 
name. The first is the old one of pressure against it with the 
flat of the hand in the direction of the pubic arch, and the sec- 
ond is that originally proposed by Fasbender, in the practice 
of which the head is grasped by the hand in such a way that 
the points of pressure are at the poles of the occipitofrontal 
diameter. To do this either the thumb or the fingers will be 
passed into the rectum, according as the woman is on her side 
or her back. All other manual measures are fragmentary and 
undeserving to be called methods. 

Manual Protection of the Perineum. — The precise mode of 
support as applied by the flat of the hand, with the woman on 
her side, is thus described by Parvin : 

"Supposing the patient to be lying on her left side, and her 
hips quite near the edge of the bed, the practitioner places his 
right hand so that the concave palm receives the convexity 
formed by the bulging perineum, the thumb is upon the right, 




356 



Labor. 



and the four fingers upon the left labium majus, while the fold 
between the thumb and index finger corresponds with the 
anterior margin of the perineum, moderate resistance is made 
to the force driving the head against the perineum, and at the 
same time the head is gently pressed toward the pubic sym- 
physis; strong pressure is to be avoided, because, if the peri- 
neum be very thin, such pressure at this thinned part may cause 
a central tear. No napkin should be interposed between the 
hand and the perineum ; the hand is not applied until perineal 
distension begins, and the application is only during a pain." 
When the patient is lying upon the back these details are 




Fig. 143. — Method of Supporting the Perineum, with the patient 
in Lateral Decubitus. 



not observed, but the head is received into the palm of the 
hand. 

This method of treating the perineum during expulsion of 
the foetal head, greatly modified as it has been from the old 
mode, well applies three out of four of the principles hereinbefore 
laid down, namely, resistance to too rapid advance of the head, 
maintenance of firm flexion, and elevation of the head well into 
the pubic arch. What are the objections urged against it? One 
objection alone, namely, that pressure, even inter mittingly, 
made against the perineum, excites the uterus to fury, through 
reflex action. Distended and benumbed as is the perineum at 
such a time, this stricture on the procedure is seen to be most 



Management of Normal Labor. 357 

ridiculous. That the latter does save some perinea, either 
wholly or partly, we are well convinced. 

The second method to which allusion has been made, namely, 
that wherein the head is brought under control by being 
grasped over the poles of its long diameter, has a variety of 
modifications. The following, described by Hart, embraces 
three of the general principles which we have laid down : 

"All the attendant can do," he says, "apart from the 
familiar means of relaxing perineal spasm by chloroform and 
hot applications, is to prevent the sinciput being forced down 
in advance of, or faster than, the occiput. He restrains the 
foetal head from advancing too rapidly. He thus has always 
to get the occiput to lead, and to get it fully born if possible. 
So far as I can judge, the best way of doing this is as follows : 
With the patient lying, of course, upon her left side, the 
attendant places the thumb of his right hand, guarded by a 
napkin soaked in hot sublimate, in front of the anus and presses 
it gently there. The pressure is not in the direction of a line 
joining bis thumb and the pubic arch, but nearly in that of the 
pelvic outlet. By this, descent of the sinciput is hindered, and 
that of the occiput is favored. When the latter is beginning to 
pass under the pubic arch, the fingers of the same hand are 
placed between it and the apex of the arch, so that when 
the occiput has cleared the arch the fingers are passed towards 
the nape of the neck, and the head thus grasped in the hand, 
the thumb lying over the sagittal suture. This gives one com- 
plete command over the head which is now engaging in the 
diameters between the nape of the neck, and forehead and 
face, and allows the whole passage with as little tear as pos- 
sible." 

Another variety of the same general method is set forth by 
Lusk as follows : 

"In ordinary cases Hohl's method, recommended by 01s- 
hausen, has rendered me excellent service. It consists in 
applying the support, not to the perineum, but to the present- 
ing part. To this end the thumb should be applied anteriorly 
to the occiput, and the index and middle fingers posteriorly 
upon that portion of the head which lies nearest to the com- 
missure. The unconstrained position of the hand enables the 
operator to exercise effective pressure in the direction of the 
vagina, while the posterior fingers favor the rotation of the 
head under the pubic arch. The patient should at the same 



358 Labor. 

time be directed not to hold her breath during the pains, except 
when they are weak and powerless." 

In Fasbender's method the patient is placed upon the left 
side, and when the head appears in the crowning stage, the 
index and middle fiugers are applied to the occiput, and the 
thumb is pushed down into the rectum, which always stands 
open, and the head thus seized by the hand and brought under 
perfect control. 

Through use of these latter methods three of the principles 
of perineal protection are perfectly applied, and we can but look 
upon them as excellent methods. 

Ways and Means for Softening and Dilating the Vulva.— The 
fourth principle is nob an essential part of any method which is 
peculiarly adapted to the moment of final escape of the head, 
but is rather preparatory to the final strain. Relaxation of 
the perineum may be favored by a variety of expedients, 
among which the application of warm emollients occupies a 
prominent place. We have frequently drawn away the peri- 
neum from the foetal head between pains, and poured into the 
space thus formed warm oil, with what seemed to us to be 
good results. Hot fomentations against the perineum are of 
utility. 

Besides such treatment, when he has special reason to fear 
rupture, the author exercises dilative pressure to the vulva 
during the latter part of the second stage. This sort of ma- 
nipulation should be begun before the head gets to pressinghard 
on the perineum, as considerable time is required to effect our 
purpose. The fingers lying in the vagina are pressed with some 
force in a backward direction during the pains, and in this 
manner the vulvar opening is gradually expanded so that less 
time will be demanded when the head shall get to the outlet. 
The pressure should at no time be very forcible, lest we inflict 
unnecessary pain and begin a laceration which later may be- 
come extensive. The manipulation should at first be made 
coincident^ with the pains, but later can be continued into the 
intervals between some of the contractions. The obstetrician 
who does not observe reasonable antiseptic precautions ought 
never to undertake this treatment. In fact, he who does not 
conduct his cases in a reasonably aseptic manner ought to 
have none to treat. 

A few years ago Dr. Goodell, of Philadelphia, recommended 
a practice intended to secure greater safety to the vulvar 



Management of Normal Labor. 359 

structures through perineal relaxation, the manipulation being 
the very reverse of that which we have been describing. When 
the head is distending the perineum, it is his plan to mitigate 
the strain at the posterior commissure by hooking the fingers 
into the anus and drawing the parts towards the pubic arch. 
The absurdity of such a recommendation is to our mind self- 
evident. The head is already pressing too hard upon the peri- 
neum, and our aim should be to guide it forwards towards the 
pubic arch, and finally through it, as rapidly as we safely can. 
To do so with undue haste would greatly endanger the peri- 
neum. A rent begun at its margin through excessive and rapid 
pressure, may easily be extended to serious proportions. This, 
of course, we wish to avoid, but to gain relaxation at the 
posterior commissure at the expense of strong pressure in what 
might be called the perineal hollow, is unwise. Far better is it 
to resist farther advance for a time, and then allow the head to 
make graduated pressure on the posterior commissure up to 
the moment of safe distension. Throwing the perineal body 
under the head, as it advances with each pain, does not serve 
promptly to prepare a safe exit for the presenting part, and 
seems to me like poor practice. It is postponing the evil mo- 
ment without changing its character. Advocates may urge 
that by prolonging the pressure on the perineum we promote 
softening of the part. This is quite true, but the part which 
most needs stretching, and that which commands the whole 
situation, is the posterior commissure, or rather that and the 
fourehette. The strong muscular part of the perineum can 
bear a powerful strain, provided the posterior commissure can 
be kept intact, or can be preserved till the head has nearly 
passed. But when, before the moment of greatest distension, 
the entering wedge is applied in the shape of a torn commissure, 
the laceration is easily carried into the depth of the perineal 
body. 

Lusk mentions a practice which has given him satisfac- 
tion, that is also intended to secure relaxation of these parts. 
" Between pains," he says, "I have been in the habit, in cases 
of rigidity, of alternately drawing the chin downwards through 
the rectum until the hand distends the perineum, and then al- 
lowing it to recede. It is astonishing how often apparently the 
most obstinate resistance can be overcome by the simple repe- 
tition of this to-and-fro movement, the parts rapidly becoming 
soft and distensible. Of course it should be discontinued the 



360 



Labor. 



moment contraction begins, and care should be taken to effect 
delivery after uterine action has subsided." This expedient is 
of some value and worthy of commendation. 

By means of the fingers, we have, in a number of instances, 
practiced expulsion of the head between pains. This can be 
done in the crowning stage of labor by placing the fingers be- 
hind the anus and pressing in the direction of the symphysis 
pubis ; but when no great descent has been attained, that is to 
say, when the head does not lie in the vulvar opening, proper 
pressure cannot be exerted without introduction of the fingers 




Fig. 144. — Method of Perineal Protection during extraction of the Head. 

(Zweifel.) 

into the rectum. Such manipulation demands the greatest 
care, as rough handling might injure the recto-vaginal septum. 
We sometimes watch descent during a pain, with the fingers in 
the rectum, and as the contraction dies out and recession of 
the head begins, we hold it forcibly against the vulvar opening. 
It is only after repeated attempts that expulsion can be effected. 
The chief advantages derivable from this mode of delivery are 
found in. the avoidance of the on-rush of propulsive energy, 
and the encounter of less resistance from muscular rigidity. 
An attentive obstetrician cannot fail to notice with what force 
the muscles contributing to the formation of the pelvic floor 



Management of Normal Labor. 361 

contract during the recurrent parturient efforts, while in the 
intervals they remain comparatively quiet. We need not add 
that this mode of delivery is adapted only to cases wherein 
there is considerable interval between pains. 

There is some danger of laceration attending delivery of the 
shoulders, but the only prevention lies in the exercise of care, 
drawing the body well forwards and keeping the elbow off 
the perineum, where it is so liable to tear the vulvar com- 
missure. 

Episiotomy. — But, we inquire, can anything be done to pre- 
serve from serious injury a perineum which, by reason of an 
anomaly in construction, or which, through want of relative 
proportion between the dimensions of the fcetus and vulva, is 
very certain to suffer laceration ? In 1836 Yon Ritgen published 
an article in which he recommended seven small incisions on 
each side of the vaginal orifice, to be made at the moment of 
greatest distension. No incision was to extend more than a 
line in depth. By this means he claimed that an increased 
vulvar circumference of two inches could be gained. The depth 
and number of the incisions have been changed by others, and, 
as we believe, the character of the operation improved. Atten- 
tion has been directed to the fact observed by every attentive 
practitioner, that the chief resistance encountered by the head 
is not at the thin border of the vulva, but at the narrow ring 
situated half an inch above, represented posteriorly by the 
fourchette, and composed mainly of the constrictor cunni, 
the trans versi perinaei, and sometimes of the levator ani 
muscles. It has been accordingly recommended that the 
incisions be made through these rigid fibers, by means of a 
blunt-pointed bistoury, or a pair of angular scissors. So far 
as practicable, the incisions should be contiued to the vagina, 
and should not exceed three-quarters of an inch in length. 
Their depth will be determined by circumstances. In cases 
where the head is about to be expelled, and firm pressure 
already exists, the bistoury may be carefully introduced, upon 
its side, between it and the vagina, three-quarters of an 
inch in front of the commissure, and section made from within 
outward. The external skin need not be included, and it may 
be protected by drawing it back before cutting. Instead of 
several very shallow incisions, we now prefer a single deeper one 
on each side ; at the points mentioned. 

In this connection it should be remembered that serious 



362 



Labor. 



perineal rupture is nearly always along the course of the raphe, 
owing to the relative weakness of the part, and the existence of 
a commissure. 

Increased danger of septicaemia has been urged against the 
operation, but the objection is void of much force. The choice 
is between two clean incisions and one gaping rupture. It may 
be said for the incisions that they are situated laterally, are 
shallow, and together do not present a greater area of absorb- 
ing surface than the central rupture which follows the expectant 
plan of management. The latter, too, owing to its location, is 
more exposed to the discharges which carry noxious germs, 




Fig. 145.— Distension and Threatened Rupture of Perineum, a, foetal 
head, b, perineum, showing lines of incision to prevent rupture. 

and from its depth, as observed by Dr. Fordyce Barker, permits 
the lochia to approach u an abundance of blood-vessels, and 
chains of lymphatic glands." 

The incisions thus made should subsequently be closed with 
No. 2 catgut. 

Frequency of Perineal Laceration. — According to Schroe- 
der's experience, the frenulum or fourchette is ruptured in 
sixty-one primiparge out of the hundred. More extensive lacera- 
tion takes place in thirty-four and one-half per cent, of first 
labors, and nine per cent, of others. 



Management of Normal Labor. 



363 



The following table, prepared by Schrenek, gives an idea of 
the frequency of rupture of the perineum. 











Proportion of 


Frequency. 




Lacerations. 


Prirniparse. Multipara 


Hildebrandt . . 356 


7.2% 


19.7 .18% 


Nippold 




1011 


11.5% 


18.7 2.2% 


Olshausen 






119 




21.1-4.7% 4.7% 


Liebmann 






1064 


15.9% 


30% 4.2% 


Mewis . 






1095 


19.8% 


31.8% 5.8% 


Winckel 








20% 




Schrenek 






847 


21.4% 


36.6% 8% 


Fasbender 






. 300 


22.3 


34% 10.6% 


Schroeder 






289 


27.7% 


34.5—37.6% 9% 


Litzmann 








27.e 





Extent of Rupture. — There are various degrees and varieties 
of perineal rupture. A mere margin, involving only the four- 
chette, may be torn, or there may be laceration of the entire 
perineal body, so as to make the rectum and vagina one horri- 
ble hiatus. Between these extremes are various degrees. 
Perineal rupture has been divided iuto classes according to va- 
riety and extent of the tear. The most simple classification is 
that which separates cases into complete and incomplete rup- 
tures. When the laceration extends through the sphincter ani 
into the rectum, it is termed complete, while anything short of 
that is called incomplete. " When the anterior edge of the 
perineum alone is referred to," says Matthews Duncan, "as for 
instance, in a laceration not amounting to half an inch in 
linear extent, it is called the fourchette." This laceration of 
the fourchette is not reckoned by all as involving the perineum 
proper, though when the term is made to include more than 
the anatomical feature known as the fourchette, we believe that 
it should be. One who has never picked up the four angles of 
even a slight laceration, and thoroughly spread out the wound, 
will be greatly surprised, when he does so, at the extent of the 
raw surface. 

"Rotten" Perineum.— -There is much difference in perinea as 
to their ability to withstand a severe strain. Every physician 
of experience has observed that moderate dilatation will at one 
time cause rupture, while excessive expansion, in another case, 
will be suffered without accident. Dr. Matthews Duncan says: 
'"There is no doubt in my mind that, in certain cases, there is 



364 Labor. 

what may be called rottenness of tissue, which destroys the 
power of the tissues to resist laceration or bursting. In some 
women, and occasionally, at least, very markedly in the syphi- 
litic, this condition is very easily demonstrated. It is a condi- 
tion also of many inflamed tissues, and this is exemplified in 
the perineum." 

The ordinary precautions against ruptured perineum have 
been considered art great length, because of their importance. 
There is nothing to be added. When we have faithfully applied 
them, we have done, in a protective way, all that it is possible 
for us to do, and yet the physician should not forget that, even 
when he has so done, his patients will occasionally suffer this 
accident. 

Delivery of the Shoulders.— When the head has finally 
cleared the vulva, the secretions should be wiped from the 
nose and mouth of the foetus, and examination then made to 

ascertain whether 
the umbilical cord 
encircles the neck. 
If the cord be 
found, it should 
be loosened by 
drawing carefully 
upon it, until it 

can be slipped 
Fig. 146. — Showing ligatures of the Umbilical ,, , -, 

~ -, , . . „ , . over the head, or, 

Cord, and point of section. ' ' 

failing in this, dur- 
ing extraction it should be passed over the foetal shoulders, so 
as to avoid strangulation of the child, and unnecessary and 
harmful traction. The cord being too short to admit of such 
treatment, or there being several turns of it about the neck, 
two ligatures may be hastily applied, and the cord severed be- 
tween them. After so doing, however, extraction must not be 
delayed, or the foetus will perish. 

In most cases the shoulders are expelled without aid. But, 
should there be delay, slight traction may be made on the head, 
while an assistant presses with some force on the fundus uteri. 
When the movement of expulsion begins, the operator's hand 
should be placed at the posterior vulvar commissure, and the 
shoulder raised with some force, as a protection to the perineum. 
As the arm, or elbow, of that side passes, special protective 
effort should be made. 




Management of Normal Labor. 365 

As soon as the child is expelled, the little finger of the ope- 
rator should be passed into the throat, and the face turned 
downwards, so as to clear the part of mucus. ■ 

Treatment of the Cord.— It is observed that when, from 
any cause, the umbilical cord is torn in twain, as sometimes ac- 
cidentally happens, there is little or no hemorrhage. It has 
been found also that, in many cases, the cord may be cut wit % 
scissors, and no ligature applied, without the occurrence of any 
extensive blood-loss. These, and other considerations, have led 
some to recommend and practice non-ligation of the cord, as 
an ordinary mode of treatment. We have given the practice a 
pretty thorough test in Hahnemann Hospital, and have found 
that, if we will but await the cessation of pulsation in the cord, 
it may be cut without fear of hemorrhage, and the case do well. 
This is probably a mode of treatment which will eventually 
become common, since it appears to possess some advantages, 
but the rule of practice is yet strongly in favor of the ligature. 
Some practitioners lay much stress on 
the quality and texture of the ma- 
terial used for ligatures, but a string 
of almost any firm material may be 
employed. The knot should be about 
an inch and a-half from the umbilicus, 

and tightly drawn, so as to prevent „ , Af7 m , ~ Tr 

™ ' » i. Fig. 147. — The square Knot. 

the possibility of hemorrhage. A lig- 
ature loosely applied is worse than none. In tightening it, 
the two thumbs should be placed back to back, and the knot 
made firm by turning them inwards. If direct traction is made, 
breaking of the string may give rise to umbilical injury from 
the severe and sudden strain which is likely to be given. A 
second ligature should then be applied on the side towards the 
placenta, and the cord severed between the tw T o knots. 

The ligature on the placental side is applied chiefly for the 
purpose of protecting the bed and clothing from unnecessary 
soiling. In twin pregnancy it is employed as a preventive of 
possible blood-loss through vascular relations between the 
placenta?. The form of knot to be used is the reef, or square 
knot, as shown in the accompanying figure. 

Early and Late Ligation. — The most desirable moment at 
which to tie the cord is a matter worthy of consideration. The 
common practice is to ligate it immediately after foetal expul- 
sion. The errors of such a practice had been pointed out by 




366 Lajbor. 

several, when Budin, in 1875, at the suggestion of Dr. Tarnier, 
made the following observations. In one series of experiments 
the cord was tied immediately after birth of the child, and the 
blood which flowed from the placental end was measured ; in the 
other series, the quantity of blood was likewise determined in 
cases where the cord was not tied until after the lapse of several 
minutes. By a comparison of the results thus obtained, he 
found that the average amount of placental blood was three 
ounces greater in the first than in the second series of experi- 
ments. Melcker estimated the entire quantity of blood in the 
infant at one-nineteenth the weight of the body, which in a 
child weighing seven pounds, would amount to six ounces. In 
1877 Schucking in similar experiments first weighed the child 
at birth, and then observing the changes which took place up 
to the moment of cessation of the placental circulation, found 
that it gained from one to three ounces in weight by the delay. 
An allowance should also be made for the portion which escapes 
observation in the interval before the weight is taken. 

What brings about the transfer of the blood from the pla- 
centa to the child is an unsettled question. Budin believes that 
with the first inspiration, the increased flow of blood to the 
lungs sets up a negative pressure in the vessels of the systemic 
circulation, so that a suction force is exerted upon the placen- 
tal blood, which condition is maintained until the equilibrium 
is again established. To tie the cord at once, therefore, pre- 
vents the adequate supply of the demands created by functional 
pulmonary activity. Schucking takes a different view, main- 
taining that, after the first breath, thoracic aspiration ceases 
to constitute an active energy, and that the main force which 
operates to cause a transfer of the blood is the compression 
exerted by the retraction, and, at intervals, by the contractions 
of the uterus. 

From clinical observation and experimental research, the 
just conclusion is that there is an element of truth in both 
these theories concerning the cause of the phenomenon in 
question. 

Several observers have shown that the loss of weight which 
occurs in the first few days after birth is less, and the period of 
loss is shorter, when the ligature is not applied until pulsation 
in the cord has ceased, and the children are more likely to be 
red, vigorous, and active. This may also explain some of the 
advantages claimed for non-ligation of the cord, inasmuch as 



Management of Normal Labor. 367 

pulsation generally ceases before the scissors are used. As 
soon as pulsation does cease, the cord ought to be cut, or 
ligatured . 

Porak and Ribemont have lately gone over this question 
thoroughly, and the general conclusions they have reached are: 
1st. Tardy ligature ensures to the infant an extra quantity of 
blood, amounting to about two and a half ounces. 2d. The 
blood contained in the placental vessels is necessary to the circu- 
latory system of the infant. 3d. The cause of the entrance of 
this blood into the foetal circulatory system, is, in particular, 
thoracic aspiration. The pressure of the uterus is purely an 
adjuvant and a secondary cause. 4th. Immediate section, and 
bleeding from the cord, should not be practiced in case of venous 
asplryxia of the new-born. 5th. Tardy ligature does not ex- 
pose the infant to any danger, whether immediate or remote. 
6th. The new-born, through tardy ligature, loses less in weight, 
and regains what it does lose more quickly. 7th. The delivery 
of the placenta would seem to be facilitated through tardy 
ligature. 8th. Ligature and section of the cord should never 
be resorted to until pulsation in it has ceased. 

The physiological time at which to ligate and cut the cord 
appears to be, as stated, immediately upon cession of pulsation 
in it. 

The Third Stage.— After severing the cord the child will be 
handed to the nurse, w T ho should wrap it up warmly and lay it in 
some safe place, deferring the necessary attentions to it until 
after the mother has been cleaned up and made comfortable. 
Meanwhile the physician attends to the duties of the third 
stage, which have reference to the promotion of uterine con- 
traction, the prevention of hemorrhage, and the expulsion of 
the placenta. To remove the placenta, when not expelled by 
the natural efforts, the old method consists of traction on the 
cord, at first in the axis of the superior strait, and finally in 
that of the outlet. But, owing to insertion of the cord into 
the placenta near its center, this sort of treatment is liable to 
create inversion of the placenta, causing it to present at the os 
uteri by its broad surface, and making delivery of it unneces- 
sarily difficult. Moreover, it has been claimed, wuth good show 
of reason, that by traction on the cord and inversion of the 
placenta, suction is liable to give rise to hemorrhage. Besides 
which, traction of this sort has been known to produce inver- 
sion of the uterus. 



^^^^mm 



3 (58 Labor. 

Delivery of the Placenta by Expression. — A method of 
placental delivery introduced by Crede a number of years ago 
is at present commonly employed by many of the best obste 
tricians. This consists in the application of a vis a tergo by 
means of the hand applied to the uterus through the abdominal 
walls, instead of the old method of vis a fronte. For a few 
minutes after delivery of the foetus the hand is laid upon the 
fundus, and slight friction made until the uterus is felt to con- 
tract with force, when, with the hand grasping the fundus as 
best it can, firm pressure is made in a direction downwards and 
backwards, i. e., towards the hollow of the sacrum. In this 
manner the placenta can usually be expressed, though repeated 
attempts may be required. The effort at expulsion is always 
to be made coincidentally with uterine contraction. 

There are at present indications of a disposition on the part 
of many who have heretofore employed this method, to aban- 
don its exclusive employment, and adopt the mixed method, 
which is certainly better adapted to the general practitioner's 
use. 

Schroeder says: "I consider it the best procedure in the 
placental period, after the expulsion of the child, not to rub or 
press the uterus, but to wait quietly until the diminution and 
ascent of the uterine body and the protuberance of the sym- 
physis indicate that the placenta is expelled from the uterine 
cavity, then, by gentle pressure, to expedite its passage 
through the vulva." 

The Combined or Mixed Method of Placental Delivery. 
—Though Crede 's method of delivering the placenta seems 
simple and easy, many have in practice, found it extremely 
difficult. This is probably owing, in most instances, to devia- 
tions from the prescribed rules, while in others it has probably 
occurred mainly through fear to apply the necessary amount 
of pressure. The author has found much greater satisfaction 
in combining the two general modes of placenta delivery, 
namely, pressure on the fundus uteri, and traction on the cord. 
We believe this mode of treatment free from serious objections, 
while it proves remarkably effective and easy. Plain traction 
outside the vulva ordinarily suffices, but if delivery be not 
easily accomplished, a short hold should be taken on the cord, 
within the vagina, so that traction can be made in a line 
approximating the axis of the brim, while with the disengaged 
hand simultaneous pressure is exerted on the fundus uteri. 



Management of Normal Labor. 



369 




Fig. 148. Delivery of the Placenta by Expression. (After Auvard.) 




Fig. 149. Delivery of the Placenta by the Mixed Method. (After Auvard.) 
(24) 



370 



Labor. 



It will occasionally be found that the cervix is completely 
occluded by the mass, and the placenta cannot be brought 
away unless the fingers first be introduced and the margin 
of it hooked down so as to secure the ideal presentation. 

Extraction should be slowly effected, to avoid tearing the 
membranes. The latter are usually left trailing in the vagina 
after birth of the placenta, and in order to secure their com- 




Fig. 150. — Rotation of the Placenta during Delivery to make a Cord of 
the Trailing Membranes. 



plete removal it is best to twist them into the form of a rope, 
and extract them with the utmost care. After expulsion or 
extraction of the placenta and membranes, the physician should 
see that the uterus remains well contracted. In most cases we 
find that organ firmly condensed in the hypogastrium, in a 
condition known as "cannon-ball contraction." 



Management of Normal Labor. 



371 



Manual Compression of the Uterus.— Throughout the 
third stage of labor, aud for a varying period thereafter, the 
hand of the physician, or some trusted assistant, should rest 
upon the fundus uteri with a moderate degree of pressure. If, 
after placental delivery, the organ manifests a decided tendency 
to relax, friction and kneading of the abdomen should be 
practiced, to excite uterine contraction. This sort of treat- 
ment should in no case be omitted, as its influence upon the 
third stage of labor, and the puerperal state, is decidedly 
salutary. 

It is the practice in Carl Braau's clinic to apply gentle fric- 
tion to the fundus uteri twice daily for 
the first two days after delivery. 

Immediate Repair of Lacera- 
tions. — After completion of the third 
stage, the cervix uteri and the vulvar 
structures ought to be carefully exam- 
ined for rents. Such examination can 
be made of the vulvar structures only 
by painstaking inspection in good 
light. Lacerations of the cervix can 
usually be made out by means of the 
finger alone, but the lips of the os are 
at this time so flaccid and irregular 
that sometimes inspection only can 
settle the question of their integrity. 
Rents are usually on the posterior 
surface of the vagina, alone, or in 
association with serious involvement Fig. 151.— Inversion of Pla- 
Of the perineum. jenta from Traction on 

xxr 4. ±u 4. u i, the Cord. 

we are not aware that much has 
anywhere been said concerning immediate repair of cervical 
lacerations, but we have been experimenting considerably our- 
selves, and are thus far well pleased with the results of the 
operation. It is doubtless an admissible operation in the 
hands of one who is accustomed to work of a similar kind in 
the vagina, but cannot yet be safely recommended to the gen- 
eral practitioner. In performing the operation we introduce 
posterior and lateral vulvar retractors, fasten a bullet forceps 
or double tenaculum into each lip at the angle of the wound, 
and, beginning at the upper angle of the laceration, close the 
rent with a continuous catgut suture. 




372 



Labor. 



Care needs to be exercised not to break the cervix by means 
of the forceps, as the tissues are exceedingly soft and easily torn. 
With respect to the perineum, there can now be no reasonable 
doubt that immediate repair is not only advisable, but, in most 
cases, obligatory. To be sure, in rare instances spontaneous re- 
pair takes place, but in these days of surgical precision, we are 
not justifiable in adopting the expectant plan of treatment. 
" Hitherto it has been my custom to apply stitches in those in- 
stances only where solution of continuity was considerable," we 
say in a recent lecture, from which we here quote at considera- 
ble length, " and the loss of firmness to the pelvic floor seemed 

decidedly inimical to the 
maintenance of organs 
in their proper relations. 
This I now believe to be 
slovenly practice. We 
ought not to forget that 
there are other consid- 
erations of a highly im- 
portant nature besides 
those just mentioned. I 
am fully persuaded that 
the time is coining, and, 
indeed, is not distant, 
when it will be regarded 
as the accoucheur's duty 
to make a careful exam- 
ination of the vulva and 
vagina immediately 
after labor, and repair 
with precision any rent which he may discover. Moreover, I 
believe you will do well to follow this practice from the very 
beginning. It will be somewhat embarrassing, and may be 
met with some criticism at first, but will become tolerated 
and at last sought. People are ultimately well pleased with 
the doctor who evinces care and consideration in the man- 
agement of his patients. Some of your colleagues and com- 
petitors will cry 'nonsense,' but you will soon silence them 
by delicately pointing out in individual cases the unfavor- 
able results of the old expectant plan of management. The 
cry of 'meddlesome midwifery' raised by some is getting to 
be stale. I do not believe that perfect license should be given 




Fig. 152. — Marginal Presentation of the Pla- 
centa. U, uterus. S, blood. P, placenta. 



Management of Normal Laboe 373 

every practitioner to do as he please; but I think the lines drawn 
by some are altogether too hard and fast. I am not running 
breathlessly after the surgical idea, yet the conviction has 
taken fast hold of me that all of our* obstetrical cases should 
be treated in accordance with approved surgical principles. 
The science and art of obstetrics have advanced side by side 
with surgery, and right there they hold their position. The cry 
of 'meddlesome midwifery' was first raised by that man who, 
in his day, was the prince of obstetricians, Blundell ; but had it 
been heeded by all, the practice of obstetrics would have re- 
mained where it then w T as, and ill-health and death after child- 
birth, though even now altogether too frequent, would have 
been as common as it then was. 

"Labor, they say, is a physiological process; and so it is. 
The effort, constantly made by nature to prevent disease germs 
getting a dangerous foothold in our bodies, is a physiological 
one, and yet, when the struggle waxes warm and we begin to 
feel it, the movement is called pathological, and artificial aid is 
invoked. Who can draw a clear line between physiological and 
pathological processes? In other words, who can say when the 
physiological bounds are passed ? Labor is truly a physiolo- 
gical process, in general, and the puerperal state is likewise 
physiological .; but certain pathological conditions are liable to 
be associated with them. My own conviction is that we are 
justified in aiding nature in her efforts, during the time when 
unusual efforts are required, so far as we safely can. After 
labor, if wounds large or small are found, standing as open 
doors for the entrance of infection, and as the possible points 
of future irritation, I say close them under antiseptic precau- 
tions. Sew up the wounds which have been made in the per- 
formance of the physiological process of parturition, and you 
will do much to w 7 ard off the evil effects which stand ready to 
assail defenseless women at this critical period. 

" The conditions surrounding such cases are not altogether 
favorable for a practice of this kind, and it may take some 
force of character to follow it. Nevertheless, unfavorable 
environment is a poor excuse for neglect of duty. It very likely 
is a case of first labor, and the woman , for a number of ago- 
nizing hours, has been receiving that astounding revelation of 
suffering common to unsuspecting primiparae. At times she 
almost sank under the power of it; but bravely rallied and 
struggled to the close. She hopes to rest in the calm succeeding 



374 Labor. 

the storm, but you decree otherwise. The genital tract must be 
examined and all rents repaired. The friends say, 'Yes, to be 
sure. Poor child.' But the patient, weary and worn, says 
' No, no. I can endure no more.' The friends say 'Yes.' but to 
one another they may add the damaging comment, 'There 
ought to have been no injuries.' All this, though unpleasant, 
ought not to deter. Do your duty. Finish up the case in a 
workmanlike manner and you shall ultimately have your 
reward. 

"I believe the details of this operation to be as important 
as those of any minor operation, and if the work is to be 
done at all, it ought to be well done. Surely, if there is a call 
for antiseptic precautions, it is right here. Look at the con- 
ditions. The woman has been in labor for several hours; the 
discharges have bathed the vulva, lying there exposed to the 
air, and doubtless undergoing some change, while the fingers of 
the attendant have been passing in and out of the vagina from 
time to time during the whole period. It may be that faeces, 
as well as urine, have found their way to the parts, and thus 
in one way and another the conditions favorable to infection 
have been strengthened. The fact is, if we expect to do a good 
piece of work it is just as essential to make elaborate prepara- 
tion for the immediate as for the secondary operation. That 
is not customary, I am free to admit; but in this particular I 
would have you practice an innovation. I want you to go out 
from the college as thorough, painstaking, skillful obstetricians. 
We want you to be all that you seem, and then w^e shall be 
proud to own you as our alumni. 

"In order that you may give these wounds proper attention, 
I recommend as a part of the regular obstetric outfit, the 
following articles : four pairs of tenaculum forceps ; one short, 
but broad, perineum retractor; two lateral retractors; several 
full-curved suture needles, an inch and a quarter to an inch and 
a half in length; a good needle-holder; plenty of catgut of 
various sizes, in juniper oil ; a large fountain syringe having a 
nozzle provided with a stop-cock, by means of which the stream 
of water can be regulated; and a good rubber protection for 
the bed. These are in addition to the usual equipment. The 
sheet should be so arranged that it will carry the water and 
blood into a receptacle placed in front of the bed. Since the 
bed is very yielding it will be necessary in most instances, to 
place a broad board of suitable length upon the springs, 



Management of Normal Labor. 375 

beneath the mattress, and also plenty of padding under the 
hips beneath the rubber. T carry in my bag a rubber sheet 
with an inflatable edge like a bed-pan, which when not inflated, 
may be rolled up so as to take but little room. Put the woman 
in position on this after she has been anesthetized, and in the 
absence of assistants, fasten up the legs by passing a sheet 
through the popliteal spaces and then around the neck, tying 
it sufficiently tight to keep the extremities out of the way. If 
she has been under an anaesthetic, we need but prolong its 
influence. If but small wounds have to be sewed, an anesthetic 
may not be required. Then turn on carbolated water from the 
syringe and thoroughly wash the parts, including the vagina. 
Use soap externally and dry with a clean towel. 

" With the instruments at hand in a bowl of carbolated 
water, you will be prepared to operate. Sew up first any 
lacerations which you find in the vagina, then those of the 
vestibule, and finally those of the perineum. Before beginning, 
be provided with two or three needles threaded with strong cat- 
gut (No. 2 being a favorite size), the threads being long, and 
deposit them with the instruments in the antiseptic solution, 
or place them in a separate dish if you prefer. They are soon 
softened by the water, and become as easily handled as silk. 
You will find it convenient to tie in the thread, since otherwise, 
during the operation, it may slip from the needle and occasion 
some annoyance. Seize the angles of any wound which you 
find, so as to steady it and make stitching easy, snip off fringes 
and irregularities which may interfere with union, and then 
close it with a continuous suture. Be careful to tie the thread 
at the finish so that it will not loosen. 

" In this manner you will close small wounds; but those of 
considerable size, and especially those which involve muscular 
structure, as in the perineum, will require additional care. The 
four corners of an incomplete laceration of the perineum should 
be picked up with the forceps, and the suturing begun above, 
that is to say, at the vaginal end. The first one or two sutures 
ought to be interrupted, and firmly tied. Then entering with 
the long thread, you may begin the continuous suture, the two 
lateral and upper forceps being steadied by assistants, and the 
whole wound kept in perfect view. You may make complete 
closure with a single row of stitches, provided the wound be 
not large; but if a single row will not draw the parts into 
perfect apposition without tension, why then, after taking a 



376 



Labor. 



few turns through the edges, you should dip down into the 
depth of the wound, and gather up the tissues therein, as you 
proceed toward the lower angle of the rent. After the suture 
emerges at the lower angle, you should take a new long thread, 
unless the first is of sufficient length to carry all the way back, 
and run a continuous suture toward the angle of the wound 
where the first needle entered, taking in the margins of the tear, 
and thoroughly closing the wound. 

"This procedure is well shown in figure 153. It will be 

observed that, in going 
forwards on the return, 
the sutures touch the in- 
tegumental surface for a 
distance, but end on the 
mucous surface of the va- 
gina. If the operation be 
well done, and the thread 
not drawn too tightly, re- 
pair will almost surely en- 
sue; the catgut sutures 
will be absorbed, and the 
occasion for dread which 
some women have of the 
taking out of the stitches 
be avoided. 

" The treatment of com- 
plete rupture of the peri- 
neum has heretofore been 
followed by incomplete re- 
pair in a large percentage 
of cases; and it is found 
necessary in any instance, 
in order to secure a perfect 
result, to pay strict atten- 




Fig. 153. — a, Forceps holding Thread 
where the continuous Suture began. 
b, The continuous Suture returning and 
closing the Wound over the deep 
stitches. 



tion to details. The wound should be drawn open, as in the 
incomplete variety, with forceps at the angles. Since the lower 
angle is split by the rent into the rectum, two forceps will there 
be required. The first attention should be given the rectal 
wound, which must be delicately and firmly closed. In this part 
of the operation interrupted sutures ought to be used. The 
needle is first made to enter at the upper angle of the wound, at 
the very margin of the flap, in a direction from the rent out- 



Management of Normal Labor. 



Si ( 



wards, splitting the part for a short distance, and emerging on 
the raw surface. It is then carried over to the opposite side 
and made to travel from the outer side towards the edge, 
splitting the flap in a similar manner, and finally emerging at 
the very margin of the flap without penetrating the rectal 
mucous membrane. It is tied on the rectal side. Other sutures 
follow till the wound is fully closed. Coaptation of this part of 
the laceration having been accomplished, the rest of the wound 
should be treated as in the instance of incomplete rupture. 
It is highly essential to success here, as in other cases, that 




Fig. 154. — Antero-posterior section, showing at e the beginning and at x 
the end of the Suturing in Complete Rupture. 

the raw surfaces be brought together in an equable manner, 
so that every part will lie in contact, and thus no pockets be 
left. 

"In putting in the catgut sutures care should be exercised not 
to place them too close together, nor to draw them too tightly. 
Perfect coaptation is the only requisite. Some little experience 
soon teaches one the art of accomplishing this in a desirable 
manner. 

"During introduction of the sutures, tension should not be 
strong on the forceps; and it is advisable now and then to 
bring the surfaces together in order to make sure that the 



378 Labor. 

. 
needle enter at opposite points, and unnecessary suture tension 

and distortion thus be avoided. 

"Carefully wash and dry the exposed surfaces, and apply to 
the vulva an antiseptic pad or napkin to catch the lochia. 

"After-treatment consists in careful cleansing of the parts, 
an occasional vaginal douche given in the most gentle manner, 
and perfect quiet. The urine should be voluntarily voided, and 
the parts immediately dried. Perfect quiet for a long period is 
essential in bad cases. In any case the patient should remain 
in bed longer than after normal parturition. The knees would 
better be padded and bound together for a few days, though 
this is not a necessary precaution. You will observe that I 
have recommended no sutures for a lacerated cervix, though I 
am quite well convinced that it is good practice to introduce 
them. I am experimenting in this direction, as some of you 
know from observation, but am not yet prepared to recom- 
mend the operation to the general practitioner. In conclusion, 
I wish to repeat with emphasis thab I believe the time is coming 
when all recognized lacerations will be repaired immediately 
after delivery, with the same punctilious care that we manifest 
in attending to the ordinary details of labor. When this comes 
to be the rule, gynaecologists will not multiply as they now do, 
for their occupation will be gone." 

Post-partum Care of the Woman.— The general condition 
of the woman, and the special state of the uterus, should be 
carefully watched for some time after delivery. First of all the 
patient should be warmly covered to prevent the occurrence of 
chilling. The manual attention given to uterine contraction, 
before mentioned, should be maintained in simple cases for at 
least fifteen minutes after placental delivery. The pulse should 
be consulted, as it is a sort of criterion from which to draw 
valuable conclusions. If it is found to be rapid, the case re- 
quires undivided attention so long as it thus continues, while 
if quiet and regular, little anxiety need be felt. The physician 
should in no case leave his patient within the first half hour 
after delivery; and if hemorrhage has been threatened, he 
should stay much longer. 

The administration of arnica should be begun immediately, 
and, in the absence of more specific indications, ought to be 
continued hourly during the first twelve or twenty-four hours. 

When the hand is removed from the uterus, the nurse, and 
other assistants, should withdraw the soiled clothes, and make 



Management of Normal Labor. 379 

the patient as clean and comfortable as possible, without much 
disturbance. It is good practice to have the nurse also wash 
out the vagina with a gentle stream of warm water, the point 
of the tube being introduced into the vagina but a short 
distance, and everything being done under antiseptic pre- 
cautions. 

The Binder. — The use of the binder is a point in practice 
over which there has been much discussion. Some practition- 
ers of much repute believe that it is not only valueless, but 
positively harmful, and utterly discountenance its use. Every 
careful observer, however, must admit that a certain amount 
of pressure is essential to the patient's perfect comfort. After 
labor women feel as though they were "falling to pieces," and 
the binder, if it does no more, certainly contributes greatly to 
their comfort. To completely fulfill the requirement, it must be 
properly applied. If too narrow it will not keep its place, and 
is liable to do more harm than good. The proper width varies 
somewhat in different cases, but the average is about ten inches, 
the intention being to cover the entire abdomen. To do this it 
must be brought well down over the hips. Almost any material 
will answer the purpose, but a strong piece of unbleached mus- 
lin is preferable. By some, a pad, consisting of a large napkin, 
or small folded towel, is placed upon the hypogastrium, beneath 
the bandage, and upon the contracted fundus uteri, but we do 
not advise its use. 

To make a neat and effective application of the binder is a 
thing not easily accomplished by the novice; and yet every 
physician ought to possess the necessary skill. Properly to 
place it under the woman's hips requires the services of two. 
When this has been done, the physician should hold the end 
near him between the thumb and fingers of the left hand, 
while he draws the opposite end tightly over it, and fastens 
pin after pin. Seven or eight safety pins should be used and, 
when fully applied, the binder must be free from wrinkles. The 
woman's toilet is completed by placing a warm and thoroughly 
aseptic napkin at the vulva to receive the discharges. If now 
comfortable, and her pulse quiet, she may be left by the physi- 
cian in care of her nurse, who, if not well acquainted with her 
duties, should receive explicit instructions. 

We cannot close this account of the general management of 
normal labor, without emphasizing the superlative importance 
of most rigid attention to cleanliness. Make sure that in no 



380 Labor. 

possible wanner septic matter reach the patient before, during, 
or after delivery. 

Therapeutics of Labor.— In the course of normal labor 
there would seem to be but few occasions for the use of reme- 
dies, but unpleasant symptoms are sometimes associated with 
the usual phenomena, and without being essential parts of the 
parturient action, are amenable to the suitable remedy. The 
indications, as applied to labor, are, of course, purely clinical, 
as we have no record of extensive provings made during the 
parturient act. We here append the following indications as 
occasional guides to the right remedies : 

Labor Pains.— Inefficient, etc.— Violent and frequent, but 
inefficient : aconite. 

Too weak, not regular: wthusa, 

Violent, inefficient : arnica. 

Tormenting, but useless, in the beginning of labor: caulo- 
phyllum. This remedy rarely fails to produce a good effect. 

Short, irregular, spasmodic, patient very weak, no progress 
made : caulophyllum, actsea rac, Pulsatilla. 

Spasmodic irregular : cocculus, Pulsatilla, caulophyllum. 

Spasmodic: causticum, ferrum, Pulsatilla. 

Spasmodic, cutting across from left to right, nausea, clutch- 
ing aboufc the navel : ipecac. 

Spasmodic, painful, but ineffectual : platina. 

Spasmodic, they exhaust her, she is out of breath : stannum. 

Spasmodic and distressing, tearing down the legs : cham. 

Insufficient, violent backache, wants the back pressed, bear- 
ing down from the back into the pelvis : kali c. 

Distressing, but of little use, cutting pains across the abdo- 
men: phos. 

Ineffectual, of a tearing, distressing character, they do not 
seem to be properly located : act sea. 

Severe, but not effective ; she weeps and laments : coffea. 

Weak, False, Deficient.— False, labor-like pains, sharp pains 
across abdomen : act sea, caul. 

Pains weak or ceasing, wants to change position often, feels 
bruised : arnica. 

Weak or ceasing, will not be covered, restless, skin cold : 
camphor; c. c. 

Deficient or absent ; she has only slight periodical pressure 
on the sacrum, amniotic fluid gone, os uteri spasmodically 
closed : belladonna. 



Management of Normal Labor. 381 

Weak or ceasing, with great debility, especially after ex- 
haustive disease, or great loss of fluids : carb. v. 

Pains become weak, flagging, from long-protracted labor, 
causing exhaustion ; patient thirsty, feverish : caul. 

Cease, from hemorrhage: china. 

Ceasing, with complaining loquacity : coffea. 

Weak, or accompanied with anguish ; she desires to be rub- 
bed: natrum m. 

False or weak, spasmodic, irregular, drowsy faint spells, with 
weak pains : nux m. 

Deficient, irregular, sluggish : Pulsatilla. 

Weak and ceasing: thuja. 

Deficient, with os soft, pliable, dilatable : ustilago. 

Suppressed, or too weak: secale. 

Cease, coma; retention of stool and urine — from fright: 
opium. 

Strong. — Excessively severe : coffea, nux v. 

Too prolonged and powerful : secale. 

Effect on Patient. — Labor-pains make her desperate, she 
would like to jump from the window, or dash herself down : 
arum tri. 

During pain she must keep in constant motion, with weep- 
ing: lycopodium. 

Cause fainting: nux v., verat. alb., puis. 

Cause urging to stool, or to urination : nux v. 

Excite suffocative or faint spells, must have the doors and 
windows open : Pulsatilla. 

Exhaust her ; she faints on the least motion : verat. a. 

Cause weeping and lamenting ; coffea. 

Location and Course of Pains. — Pains principally in the 
back: caust. 

Pains worse in the back : nux v. 

Pains worse in the abdomen : Pulsatilla. 

Pains run upward: lycopodium. 

Pains like needles in the cervix, especially with rigid os : cau- 
lophyllum. 

Special and Peculiar Symptoms. — Cardiac neuralgia in 
parturition: actwa. 

During labor cannot bear to have her hands touched: 
china. 

With every uterine contraction, violent dispncea which seems 
to neutralize the labor-pains : lobelia. 



382 Labor. 

Labor progresses slowly, pains feeble, seemingly from sad 
feelings, and forebodings: nat.mur. 

Cessation of labor-pains ; retention of stool and urine, often 
from fright: opium. 

Contractions interrupted by sensitiveness of vagina and 
vulva: plating. 



Use of Anesthetics. 383 



CHAPTER IV. 
USE OF AXESTHETICS IN MIDWIFERY PRACTICE. 

In treating the subject of anesthetics in obstetrical practice, 
we should divide cases into two general classes : 1. Cases of 
normal labor, wherein we seek merely to mitigate the ordinary 
pangs of childbirth, and 2. Cases of an abnormal, or unusual, 
nature, wherein operative interference is necessitated. 

1. Cases of Normal Labor.— Obstetrical Anesthesia — 
The use of anesthetics in normal labor differs essentially from 
its employment elsewhere, in the design of its employment, and 
the extent to which its action is carried. We aim in such cases 
not completely to annul sensibility, and subdue muscular resist- 
ance; but merely to modify the agony associated with the 
propulsive stage of labor. When from purpose or accident the 
anesthetic influence is permitted to exceed this limit, new 
dangers arise, and fresh complications are met. To accomplish 
our purpose, continuous inhalation is not required, and should 
not be permitted, but the lethean vapors ought to be applied 
just before and during the pains. 

The form of anesthetic best adapted to such purposes is 
unquestionably chloroform. It is more speedy, pleasant, and 
energetic in its effects than ether, and in parturition it has 
proved to be quite as safe. In surgical practice its effects have 
occasionally proved fatal, but when administered during labor, 
according to the directions which follow, scarcely a death has 
resulted. 

Parturient women are easily put under its influence to the 
extent required for immediate purposes : a few inhalations of 
its vapors, begun just before the expected recurrence of a pain, 
and continued during it, being sufficient to allay excessive 
sensibility, and quiet the nervous erethism so often observed. 
The nurse, or some self-possessed assistant, is instructed to pour 
upon a folded handkerchief or napkin fifteen or twenty drops 
of the chloroform, and place it within about half an inch of 
the nose and mouth, thereby giving free access to atmospheric 
air. We have found Esmarch's inhaler very convenient for the 
purpose. None of the chloroform should be permitted to touch 
the patient's skin, as the smarting produced by it would be 
liable to excite fear. It is a good plan to apply the chloroform 



384 Labor. 

to the handkerchief soon after the close of a pain, and then roll 
the latter tightly in the hand to prevent evaporation, until the 
pain is about to return. Otherwise there is liability to delay, 
and the patient is as greatly annoyed by the bungling work of 
the person in charge of the anesthetic as by the labor-pains 
themselves. By such administration of chloroform, conscious- 
ness is not interrupted. The patient may at the time declare 
that her sufferings are nearly as keen as before ; but when the 
labor is past, she will be enthusiastic in her praise of the virtues 
of the anesthetic. Women w 7 ho have once taken it are not 
willing to be deprived of its soothing influences in subsequent 
labors. 

The usual objections raised against the use of chloroform in 
labor are not here forcible, since the effect is so moderate that 
it is not capable of materially modifying the pains, precipitat- 
ing post-partum hemorrhage, or producing any of the other 
ills sometimes attributable to a use of the drug when admin- 
istered more freely. 

The period in labor when the use of an anesthetic should be 
adopted varies in different cases. It is wise, however, to defer 
anesthesia until near the close of the second stage. When once 
begun, its action must be maintained until the close of foetal 
expulsion, as the woman will not tolerate a suspension of the 
pain-soothing influences. Hence, to begin early involves long 
continuance. The most intense pain is suffered in the latter 
portion of the propulsive stage, and this part of labor, if any, 
ought to be lightened. In some instances of extreme excita- 
bility, and terrible suffering, the chloroform may, with perfect 
propriety, be earlier exhibited. 

2. The Use of Anesthetics in Operative Midwifery — 
Surgical Anesthesia. — The effect of the anesthetic, in those cases 
where operative procedures are necessary, is carried to a greater 
extent, and, possibly, involves the patient in greater danger. 
That there is a certain degree of peril to life associated with the 
administration of any anesthetic, no one will question, and that 
it is greater in the instance of chloroform, none who have 
familiarized themselves with the general subject of anesthetics 
will presume to deny. Every few weeks a case of death under 
chloroform finds its way into public print, thus giving strength 
to popular fear. And yet a careful analysis of such fatalities 
generally discloses, as an efficient cause of the accident, a fla- 
grant disregard of the rules laid down for the administration 



Use of Anesthetics. 385 

of this potent, and hence dangerous, substance. The fatalities 
occurring in the dentist's chair largely preponderate, the 
patient occupying a semi-recumbent position, which is wholly 
at variance with the teaching of all clinicians. 

Attention should be directed to the difference in point of 
mortality under anesthetics between surgical and obstetrical 
patients. In surgery we have many recorded cases of death, 
and their number is being augmented from time to time ; but 
this is not true of midwifery. In fact, but few fatal cases in the 
latter branch of practice have ever gone upon record. The ex- 
planation of such divergent results is not altogether satisfac- 
tory, but we opine that it may be found in the increased cardiac 
energy growing out of the circulatory changes of pregnancy, 
elsewhere described. But whatever our theories regarding the 
cause, the truth remains, and has become familiar, even to the 
general public. 

Anesthetics are said to predispose to post-partum hemor- 
rhage, which is generally a complication directly dependent on 
atony of the uterine muscles. Extreme vascular fullness is 
maintained by the flaecidity of the tissues, while the exposed 
vessels at the placental site freely bleed. The effect of anes- 
thetics on uterine contraction is marked, as the author has re- 
peatedly demonstrated. This effect is rather more decided in 
chloroform than in ether inhalation. A moderate degree of 
anesthesia may be produced without essentially modifying 
uterine action; but as the impression becomes more profound, 
the contracting organ is partially or wholly subdued. If this 
is the effect of anesthetics on the uterus during labor, when the 
organ is stimulated to action by its contents, we should be 
prepared to find a corresponding condition protracted some- 
what into the post-partum stage. That we do find more or less 
relaxation after extrusion of the foetus and secundines in such 
cases, is beyond question; and yet it is not so marked, nor so 
persistent, as some suppose. Remove the vapors from the 
woman's nostrils during labor, and the contractions which 
have been extremely feeble, or altogether absent, are soon re- 
newed. In like manner after delivery, when the more profound 
effects of the chloroform pass away, uterine atony generally 
gives place to a favorable tone of the muscular fiber. The re- 
sult is that hemorrhage of moment rarely ensues. Occasionally 
there is a sudden profuse gush of blood soon after the placenta 
is removed, especially when the anesthetic influence has been 

(25) 



386 Labor. 

maintained to the very close of the second stage, or longer ; 
but hypogastric pressure, and moderate use of cold water, are 
nearly always capable of speedily arresting the flow. In the 
Hahnemann Hospital it is our custom, as a preliminary to the 
introduction of a class of students, to bring the woman pro- 
foundly under the influence of chloroform ; and though 
narcosis is frequently maintained for a period of one and a 
half, or two hours, among the hundreds of women confined 
there during the past few years, not a single case of alarming 
hemorrhage has been met. Our practice is to keep a close 
watch over the patient for a considerable time after delivery, 
and give attention to the first indication of trouble. Pressure 
is made on the fundus uteri for fifteen or twenty minutes after 
foetal and placental expulsion, in ordinary cases, and longer in 
those presenting suspicious symptoms. If the uterus is felt to 
relax beyond a normal limit, and does not respond at once to 
abdominal pressure, the vulva is inspected, and, if necessary, 
cold applications, and manual irritation of the os uteri, are 
employed. It is rare that more energetic measures are re- 
quired. 

The question has often been asked — Does an anesthetic 
administered to the mother, produce any effect on the child in 
utero? We have been led by experience to give an affirmative 
reply. For example, in a difficult instrumental case which came 
under the writer's care, wherein sulphuric ether was adminis- 
tered for an uncommonly long time, the child, though but a few 
minutes before birth it was proved by auscultation to be living, 
was still-born, and resisted all efforts at resuscitation. About 
forth-eight hours subsequently, dissection of it was begun by 
some students, and when the viscera were exposed, the odor of 
ether was distinctly recognized. 

In most instances, where the mother has been long subjected 
to anesthesia, the child is comparatively inactive for some time 
after expulsion. It is really uncommon for children born under 
such conditions to utter theories so generally heard at the birth 
of children whose mothers have not been under anesthetic in- 
fluences. And yet, that decidedly deleterious effects are often 
produced, there is much reason to doubt. 

Dr. J. C. Eeeve, in the "American System of Obstetrics," 
says that a careful study of the subject of accidents from 
chloroform during parturition justifies the following state- 
ments : 



Use of Anesthetics. 



387 



1. But one well authenticated case of death is on record 
where the administration was by a medical man, and in that 
case no autopsy was held. 

2. Dangerous symptoms have occurred but a very few times, 
and then almost always from violation of the rules of proper 
administration. 

3. The danger when chloroform is used only to the extent 
of mitigation or abolition of the suffering of childbirth 
is practically nil; when carried to the surgical degree for 
obstetric operations, the danger is far below what it is in 
surgery. 

4. No proof can be furnished that the parturient woman 
enjoys a special immunity from the dangers of anesthetics, 
though facts seem to indicate that such exists. Her best safe- 
guard lies in the care and watchfulness 
of the administrator. 

Rules for Administering Anes- 
thetics. — The general rules for admin- 
istering anesthetics are pretty well 
understood, even by tyros, and still 
there is frequent disregard of them. 
The mode of administering chloroform 
differs materially from that of ether. In 
bringing a patient under the influence of 
the latter, a cone, or an inhaler of some 
other form, is generally employed, which 
is held closely down over the nose and 
mouth, so that all the atmosphere which 
enters the lungs is loaded with ether vapors, taken from the 
saturated sponge in the apex of the cone. Such a use of 
chloroform would be dangerous in the extreme. 

In the administration of chloroform the following rules 
should be observed : 

First: — The patient must occupy the recumbent posture. 

Second: — The article or apparatus by means of which the 
chloroform vapors are conveyed to the patient, must be so 
placed or arranged as not to exclude a free supply of atmos- 
pheric air. 

Third: — Both respiration and pulse should be attentively 
observed from first to last. 

It has been repeatedly demonstrated that deviation from a 
horizontal position augments the patient's danger. The 




Fig. 155.— A His' Ether 
Inhaler. 



388 Labor. 

head should lie in a line with the longitudinal axis of the 
trunk. 

The supply of atmospheric air must be more copious than 
that which is given with ether inhalation. A folded handker- 
chief, or napkin, is a convenient medium, on which should be 
poured but a small quantity at a time, and then placed within 
one-half or three-quarters of an inch of the patient's mouth and 
nose. Esmarch's inhaler is more convenient and economical 
than any other means. The patient should be directed to 
breathe deeply and regularly, while fear and excitement ought 
to be allayed as far as possible, by cheerful words and a calm 
bearing. The supply of chloroform may be renewed as often 
as circumstances seem to require, the intervals being varied to 
correspond with the woman's condition, and the facility with 
which anesthesia is produced. These are important considera- 
tions, since it is very certain that danger bears a marked 
relation to the intensity of the impression, and the rapidity of 
its production. 

Neither anesthetic should be administered without the 
closest attention being directed to the pulse and respiration. 
When employed in normal labor for the purpose merely of dull- 
ing the sensibilities, this is hardly so essential, though it should 
not be forgotten that in other than midwifery cases, death has 
occurred, in quite a proportion of instances, at the very begin- 
ning of the anesthetic process. When carried to the extent of 
complete narcosis, the rule must be scrupulously adhered to, if 
one would keep within the bounds of comparative safety. Nor 
should these observations be intrusted to a person wholly 
unacquainted with the phenomena developed by anesthetics, if 
it is possible to secure the aid of one qualified to fill the posi- 
tion. To do otherwise is to subject the woman's life to unneces- 
sary risk, one's self to much solicitude, and to merited denunci- 
ation in case of a fatal result. 

After making the most elaborate provision for the adminis- 
tration of this powerful drug, the operator should on no account 
suffer himself to become oblivious to his patient's condition. 
When the operation is difficult, and attended with vexatious 
occurrences, one easily becomes so deeply engaged in the work 
immediately in hand as to remit his watchfulness over impor- 
tant concomitants — a state of mind against which he cannot 
be too guarded. 

We shall not here enter into an account of the symptoms of 



Use of Anesthetics. 



389 



fatal cases, or the treatment to be adopted ; but for an extended 
discussion of these we refer the student to elaborate works on 
surgery and to special treatises. 

"Chloroform is especially indicated— 

"1. In primipara? who are nervous and excitable, and in 
whom the pain may even cause delirium ; also in those with 
whom the labor is greatly prolonged, thus becoming a source 
of danger. 

"2. In all cases in which there is a spasm, contraction, or 
rigidity of the neck or body of the uterus. Contra-indications 
are the absence of severe suffering, the existence of placenta 
prsevia, general prostration, disease of the circulatory or 
respiratory organs, cerebral disease, alcoholism, etc." 




Fig. 156. — Esmarch's Inhaler. 



390 Labor. 



CHAPTER V. 

THE MECHANISM OF LABOR. 

The Various Positions of the Foetus.— This is a subject 
which, to the student, is full of difficulty, and to elucidate it is 
no easy task. One of the most conspicuous factors in the pro- 
duction of confusion is the adoption of numerals to designate 
the various positions which are met. Most authors give to 
every presentation four positions, which are designated by the 
numbers one, two, three and four. For example, the left oc- 
cipitoanterior position is the first, and the right occipito-ante- 
rior is the second. The adoption of these designations, it must 
be confessed, is a saving of some words at the moment ; but to 
give the student a, perspicuous and comprehensive view of the 
different positions, and their relations, demands an exhaustive, 
and, we may add, unnecessary effort. 

As a preliminary to the study of this subject one must have 
a clear conception of the cardinal features of the pelvis, which 
have been elsewhere pointed out. With a knowledge of the 
form of the pelvic brim, outlet and cavity, the situation of the 
iliopectineal eminence and the acetabulum, and the relative 
measurements of the various diameters, and finally the bounda- 
ries of the false and the true pelvis, one is prepared to under- 
stand that which here follows. 

The Theory of Classification.— The four positions into 
which the various presentations are divided are based upon the 
theory that the long diameter of the presenting part occupies 
an oblique position with reference to the pelvis. That the 
theory does not hold true in all cases, is manifest to every ob- 
stetric practitioner. The long diameter is sometimes, though 
rarely, at the brim, in the conjugate of the pelvis ; and again 
it occupies the transverse diameter. In the latter instance it 
always rotates into an oblique diameter, sooner or later, and 
therefore becomes one of the regular positions ; while instances 
of the former are so rare as to make a single exception of no 
great importance. For practical as well as theoretical pur- 
poses, perspicuity would lead to an approval of the division. 

When the vertex presents, the occiput is regarded as the cardi- 
nal feature, since it is in advance, and from the direction it 
assumes the positions are described, or numbered. With the 



Mechanism of Labor. 391 

long diameter of the head in an oblique pelvic diameter, the oc- 
ciput must be either forwards and to the left, or backwards and 
to the right ; forwards and to the right, or backwards and to 
the left. When forwards and to the left it is the first position ; 
when forwards and to the right it is the second position ; w T hen 
backwards and to the right it is the third position ; and when 
backwards and to the left it is the fourth. 

When the face presents, the chin corresponds, so far as the 
mechanism of labor is concerned, to the occiput in vertex pres- 
entation, and the direction of that part determines the 
position. When backwards and to the right it is the first posi- 
tion; when backwards and to the left, the second; when for- 
wards and to the left, the third ; and when forwards and to the 
right, the fourth. 

When the pelvic extremity presents, one pole of the long 
diameter does not take precedence over the other, since it is 
immaterial to the easy and natural performance of the mechan- 
ism of labor whether the right or the left trochanter looks 
forwards. When the bi-trochanteric diameter is in the left ob- 
lique pelvic diameter, and the left hip is forwards and to the 
right, it is the first position; when in the right oblique diame- 
ter, and the right hip is forwards and to the left, it is the sec- 
ond position ; when in the left oblique and the right hip is 
forwards and to the right, it is the third position ; and when in 
the right oblique diameter, with the left hip forwards and to 
the left, it is the fourth position. 

When the foetus presents transversely, four positions may 
also be described. If the dorsum is forwards, and the head lies 
to the right, it is the first position ; if the dorsum is forwards, 
and the head lies to the left, it is the second position ; when the 
dorsum is backwards, and the head lies to the left, it is the 
third ; and when the dorsum is backwards, and the head lies to 
the right, it is the fourth. 

These are the four positions of the various presentations. 
They have been otherwise named by some authors. 

The Basis of Classification. — It must not be supposed that 
the classification of positions is made upon mere arbitrary prin- 
ciples, though from the first study of it this may seem to be 
true. Our attention has thus far been addressed to the various 
features of the presenting parts, but we will now regard the 
position of the trunk. 

With respect to the direction of the back, it should be said 



392 



Labor. 




Fig. 157. — First position of the Vertex. Fig. 158.— Second position of the Vertex. 




Fig. 159. — Third position of the Vertex. Fig. 160. — Fourth position of the Vertex. 



Mechanism of Labor. 



393 





Fig. 161. — First position of the Face. Fig. 162. — Second position of the Face. 




Fig. 163.— Third position of the Face. Fig. 164.— Fourth position of the Face. 



394 



Labor. 




Fig. 165— First position of the Breech. Fig. 166.— Second position of the Breech. 




\ i / 

Fig. 167.— Third position of the Breech. Fig. 168.— Fourth position of the Breech. 



Mechanism of Labor. 



895 




Fig. 169. — Second position of Footling presentation. 




Fig. 170. — Fourth position of the Feet. 



Fig. 171.— Third position of Transverse 
presentation. 



396 



Labor. 




Fig. 172. — Second position of Transverse 
presentation. 



Fig. 173.— Fourth position of Transverse 
presentation. 




Fig. 174. — First position of the Vertex. Fig. 175. — First position of the Breech. 



Mechanism of Labor. 



397 



that, like the position of the head, it is not always oblique ; still, 
practical, as well as theoretical, purposes are just as well served 
— we may say, are better served — by assuming that it is. The 
long axis (bis-acromial) of the trunk forms a right angle with 
the long axis ( occipitofrontal in vertex presentation, and 
fronto-mental in face) of the head. Accordingly we observe 
that the dorsum of the foetus coincides with the occipital pole 
of the long diameter of the vertex, and the frontal pole of the 
long diameter of the face. The bi-trochanteric diameter of the 
pelvis is the long diameter of the presenting part, when the 




Fig. 176. — Second position of 
the Vertex. 



Fig. 177. — Second position of 
the Breech. 



pelvic end is in advance. In the first position of vertex presen- 
tation the occiput lies to the left ilio-pectineal eminence, and 
constitutes the left occipito-anterior position. Now, assuming, 
as we do, that the foetal back corresponds in direction with the 
occiput, this position might well be designated the left dorso- 
anterior position of the vertex. Let us now reverse the ends 
and cause the breech to present in the first position, and we 
have the left dorso-anterior position of this presentation. We 
will now return the child to the first position of the vertex, and 
then by extension of the head, i. e., by tipping the head back- 
wards, convert it into the first position of the face, and we 
find that this may likewise be described as the left dorso-ante- 



398 Labor. 

rior position — not of the vertex, not of the breech— but of the 
face. Furthermore, we will now turn the head away from the 
brim and lay it in the right iliac fossa, and we have the first 
position of transverse presentation, which may also be desig- 
nated the left dorso-anterior. 

What is true of the first position is also true of the second, 
third and fourth positions. In the second position the dorsum 
of the foetus is forwards and to the right, and it may be 
graphically described as right dorso-anterior. When the head 
presents, it is right dorso-anterior position of the vertex or 
face ; when the pelvis presents, it is right dorso-anterior of the 
breech, knees or feet ; and when the presentation is of the side 
of the foetal oval, then it may still be designated the right 
dorso-anterior position. In the third position of any pre- 
sentation, the back of the foetus lies backwards and towards 
the woman's right, and in the fourth position of any presenta- 
tion, the dorsum is turned backwards and towards the woman's 
left. By such generalization, we obtain a comprehensive view 
of the entire subject of positions. 

From what has been given on this topic we may draw the 
following conclusions : 

1st. That the underlying principle of classification is not 
so much the direction of the cardinal features of the presenting 
part, as the direction of the foetal dorsum. 

2d. That the first and second positions of all presentations 
are dorso-anterior, — the first, left dorso-anterior, and the 
second, right dorso-anterior; and the third and fourth posi- 
tions are always dorso-posterior, — the third being right dorso- 
posterior, and the fourth, left dorso-posterior. 

3d. That in the first and fourth positions of all presenta- 
tions, the dorsum of the foetus is directed towards the woman's 
left, — the first somewhat forwards, the fourth somewhat back- 
wards ; and in the second and third positions of all presenta- 
tions, the dorsum is turned towards the mother's right,— the 
second, somewhat forwards, the third, somewhat backwards. 

The Relative Frequency of Positions.— Dubois found the 
first position in 70.83 per cent., and the third in 25.66 per 
cent, of all his cases. Dr. Joseph G. Swayne, on the contrary, 
out of 1 ,000 cases had the first position in 792 (79.2 per cent.), 
the second in 152 (15.2 per cent.), the third in 19 (1.9 per 
cent.), and the fourth in 37 (3.7 per cent.). 

Out of 169 vertex presentations in our hospital practice, 



Mechanism of Labor. 399 

there were 118 of first position, 35 of second, 7 of third and 9 
of fourth. 

Points of Coincidence Between the Various Positions*— In 
vertex presentation, the first and second positions agree in one 
particular, namely, they are both occipito-anterior positions,— 
the first looking to the left, the second to the right; and the 
third and fourth agree in being occipito-posterior positions, — 
the third directed towards the right, and the fourth towards the 
left. The first and fourth correspond in being left occipital 
positions ; that is to say, the occiput in both instances is turned 
towards the left,— in the first, somewhat forwards, in the fourth, 
somewhat backwards. The second and third are alike in the 
general direction of the occiput,— both looking to the right, — 
the second turned somewhat forwards, and the third somewhat 
backwards. Again, the first and third agree in respect to the 
oblique pelvic diameter (right oblique) in which they lie, but 
the poles are reversed, so that the first is the left occipito- 
anterior position, and the third the right occipito-posterior. 
The second and fourth correspond in similar respects. They 
occupy the left oblique pelvic diameter,— the second being the 
right occipito-anterior, and the fourth the left occipito-posterior 
position. 

Face Presentation. — Briefly stated, the positions of the face 
coincide in certain particulars which are determined by similar 
principles of classification as are those of the vertex. The first 
and second are mento-posterior positions, the chin in the first 
looking to the right, and in the second, to the left. The third 
and fourth are mento-anterior positions,— the chin in the third 
being directed to the left, and in the fourth, to the right. The 
first and fourth correspond in the lateral direction of the chin, 
— in the first it being backwards and to the right, and in the 
fourth, towards and to the right. The coincidence between the 
second and third is similar, — in the second the direction being 
backwards to the left, and in the third forwards to the left. 

The first and third and the second and fourth are alike in 
the pelvic diameters occupied by the long facial diameter, — the 
first being right mento-posterior, and the third, left mento- 
anterior; while the second is left mento-posterior, and the 
fourth right mento-anterior. 

Breech Presentation. — The first and second positions of the 
breech agree in that the right trochanter of the foetus looks 
towards the left, in the first position somewhat backwards, and 



n 



400 Labor. 

in the second forwards. Likewise the third and fourth positions 
resemble one another in that the right trochanter is turned to 
the mother's right, — in the third position it being forwards, and 
in the fourth backwards. The first and third are identical in 
the direction of the bi-trochanteric diameter (left oblique), but 
in the first position the right trochanter is at the left ilio-sacral 
synchondrosis, and in the third is at the right ilio-pectineal emi- 
nence. The second and fourth positions coincide in the pelvic 
diameter occupied (right oblique), but in the second the right 
trochanter is at the left ilio-pectineal eminence, and in the 
fourth, at the right ilio-sacral synchondrosis. 



Mechanism of Labor. 401 



CHAPTER VI. 

THE MECHANISM OF LA BOB— Continued. 

The mechanism of labor varies greatly with the character of 
the presentation. The varieties of these, and their positions, 
have already received attention, and but a few general remarks 
with regard to them need here be made. Vertex presentation 
represents the normal type of labor, and is alone entitled to be 
regarded as strictly normal. The other varieties are relatively 
infrequent, and present characters which deviate from the 
phenomena usually observed. 

Vertex Presentations. — Some of the ancients believed that 
the head passed through the pelvis in the same manner as a 
semi-organized clot of blood, or a mass of hardened faeces, with- 
out reference to those nice laws of flexion, rotation, extension 
and restitution, now so Avell understood to have an important 
bearing in every case. Others believed that the child by its 
own spontaneous efforts pushed its way through the pelvis— 
that it verily crept into the world. The origin of the present 
theories regarding the mechanism of labor may be traced to Sir 
Fielding Ould, who in 1742 published a work which contained 
some of the ideas still extant. In 1771, Saxtorph, of Copen- 
hagen, and Solayres de Renhac, of Montpellier, simultaneously, 
and without mutual consultation or knowledge, published 
essays which agreed that in natural labor the long diameter of 
the child's head enters the pelvis in an oblique direction, and 
that in a large proportion of instances it occupies the right- 
oblique diameter, the poles of which are the left ilio-pectineal 
eminence and the right ilio-sacral synchondrosis. Through 
the strong advocacy of Baudelocque these ideas were quite 
generally accepted, but certain erroneous notions crept in, and 
the matter was finally cleared up and simplified by Naegele, of 
Heidelberg, in 1818. 

" Vertex."— The term " vertex " will be understood to signify 
the upper surface of the head, but it may be well to say that by 
it is meant the crown, or that part of the head embraced within 
the limits of lines connecting the posterior fontanelle, the 
parietal eminences, and the anterior fontanelle. 

Relative Frequency of Vertex Presentations.— Out of 
93,871 births collected by Spiegelberg, from private practice, in 

(26) 



402 Labor. 

over ninety-seven per cent, the vertex presented. Dubois, in 
2,020 deliveries at term, found' 1,913 vertex presentations. 
Mine. Boivin in 20,517 births, found 19,810 vertex presenta- 
tions. The probable cause of this has already been considered. 

Relative Frequency of First Position. — As elsewhere stated, 
the first position of the vertex is found in a large proportion 
of cases. The cause of this is not perfectly understood, but 
Simpson attributes it to the presence of the rectum on the left 
side of the pelvic brim. 

It has been suggested that it probably results from the fact 
that the uterus is usually rotated in such away upon the spine, 
that the right side inclines obliquely backwards, while the left 
side is turned somewhat towards the front. 

Changes of Presentations and Positions. — The foetus may 
change its presentation and position at any time during preg- 
nancy, but, of course, with less facility in the latter part of this 
period. Not rarely does such a change take place even after the 
beginning of labor, whether remedies have been administered 
with a view to effect a change or not. 

From extensive observations made by him, Schroeder arrived 
at the following conclusions : 

1st. The foetal presentation rarely remains motionless from 
the end of the seventh or the eighth month until the time of 
labor. In 113 women examined once only, change of presenta- 
tion was encountered in 31.86 per cent, of the cases. Prirni- 
paras 30 per cent.; multiparas 36.36 per cent. In 56 women 
examined twice, change of presentation occurred in 59 per 
cent, of the cases. Primiparas 52 per cent.; multipara? 66 per 
cent. In 33 women examined three times, change of presenta- 
tion was found in 76 per cent, of the cases. Primiparas 72 per 
cent.; multiparas 88.9 per cent. In 28 women examined several 
times, change of presentation was found in 89.3 percent, of the 
cases. Primiparse 89.3 per cent.; multiparas 100 per cent. 

2d. The changes are less common in primiparas than in 
multiparas. 

3d. They become rarer as we approach term. 

4th. Even when the head is fixed in the superior strait, 
change of presentation is possible. 

5th. When the head is completely within the lesser pelvis, 
change of position occurs in only 10 per cent, of the cases. 

6th. Changes are more common with contracted than with 
normal pelves. 



Mechanism of Labor. 403 

The following table, taken from Schroeder, will show the 
frequency and variety of these changes of presentations and of 
positions : 







Presentations 


and Positions. 


All cases 
Times. 


Primiparae. 
Times. 


Multipara? 
Times. 


1st position of Vertex into 2d position of Vertex . . . 


50 


33 


17 


1st 


a 


" 


' 2d 


Breech. . . 


2 


1 


1 


1st 


" 


u 


" 1st 


Shoulder . 


3 


2 


1 


1st 


a 


a 


' 2d 


" 


2 


1 


1 


2d 


a 


it 


" 1st 


Vertex. . . 


71 


43 


28 


2d 


u 


u 


' 1st 


Breech . . . 


1 





1 


2d 


" 


ti 


" 2d 


" 


3 


2 


1 


2d 


it 


" 


" 1st 


Shoulder. 


5 


3 


2 


3d 


u 


" 


" 2d 


" 


1 





1 


1st 


" 


Breech 


' 1st 


Vertex . . . 


3 


1 


2 


2d 


" 


" 


" 1st 


Face 


1 





1 


2d 


" 


<( 


" 1st 


Vertex . . . 


9 


3 


6 


2d 


it 


u 


" 2d 


" 


3 





3 


2d 


" 


ti 


" 2d 


Shoulder . 


2 





2 


1st 


it 


Face 


" 1st 


Vertex . . . 


1 





1 


2d 


a 


" 


tt 2d 


" 


1 





i 


1st 


" 


Shoulder 


" 1st 


4< 


4 


1 


3 


1st 


t< 


" 


" 2d 


it 


7 


4 


3 


1st 


a 


" 


" 2d 


Shoulder. 


2 





2 


2d 


u 


it 


" 1st 


Vertex . . 


4 


2 


2 


2d 


a 


a 


" 2d 


" 


5 





5 


Unki 


iown 


Shoulder 


a 2d 


« 


2 


2 







" 


" 


" 2d 


Breech . . 


1 





1 



Conditions at the Beginning of Labor. — At the beginning of 
labor, the presenting head, covered by the uterine tissues, is 
usually found just above the brim, and occupies with its long 
diameter an oblique diameter of the pelvis. 

Conditions of the Foetus which Favor Expulsion.— The 
mechanism of labor in vertex presentations is usually described 
as consisting of a series of movements, termed (1) descent, 
(2) flexion, (3) rotation, (4) extension, (5) restitution. 

A knowiedge of these movements as they occur in labor is 
highly essential to a proper comprehension of the mechanism 
of parturition, and the intelligent practice of the obstetric art. 

Mechanism of Labor in the First, or Left Occipito-An- 
terior, Position. — It should be remembered that, in the first 
position of the vertex, the long diameter of the head occupies 
the right oblique diameter of the pelvis, the occiput being di- 
rected to the left iliopectineal eminence, and the forehead to 
the right sacro-iliac synchondrosis. The dorsum of the foetus 
is thus brought to the mother's left side. 



404 



Labor. 



Parallelism 01 the Bi-parietal Plane to the Plane of the 
Brim. — The head has usually been described as entering the 
brim with the right parietal eminence on a lower plane than 
the left; but this idea is being abandoned. The plane of the 
brim and the bi-parietal plane are probably at that stage of 
advancement coincident. 

Descent and Flexion. — Descent and flexion are closely allied 
movements. As the head descends and encounters the bound- 
aries of the brim, the force is such as to cause flexion. The long 
diameter of the head represents a lever, with the fulcrum at the 
occipito-atlantoid articulation, the anterior being the long arm 

and the posterior the 
short. It is clear, then, 
that, as the head descends 
and meets resistance at 
the brim, the force trans- 
mitted through the spine 
will cause descent of the 
occiput, and effect flexion 
of the chin on the ster- 
' num. The degree of flex- 
ion will be proportioned 
to the extent of the ac- 
tion, and the force and 
extent of resistance en- 
countered. 

Direct Descent of the 

Head. — The descent of the 
Fig. 178.-First position of the Vertex. head doeg ^ in the 

early part of its course, closely follow the axis of the pelvic 
canal; but the movement is directly downwards and back- 
wards in the axis of the brim, until it touches the floor of 
the pelvis, and meets there with resistance which turns it 
forwards to the pubic arch. 

Passage Through the Pelvic Cavity. ,-vAs the head passes 
through the cervix uteri, flexion usually becomes extensive, so 
that the chin is pressed well upon the sternum. This movement 
not always being requisite, does not always occur, the exception 
being found in a small head, or an exceptionally soft and di- 
latable cervix. The advantage of this condition of flexion is 
plain, since it will be seen that by means of it shorter diameters 
are brought to bear upon the pelvic dimensions. 




Mechanism of Labor. 



405 



A further advantage derived from head flexion has been 
described by Pajot: "The foetus in its entirety may be 
regarded as a broken, vacillating rod, which is movable at the 
articulation of the head and trunk, but a solid thus disposed 
presents conditions unfavorable to the transmission of a force 
acting principally upon one of its extremities ; it follows, there- 
fore, that, previous to flexion, the uterine action, pressing upon 
the pelvic extremity to promote the advance of the fcetus, is 
lost in great measure in its passage from the trunk to the head, 
by reason of the mobility of the latter; but the cephalic 
extremity, once fixed upon the thorax, is most advanta- 
geously disposed to participate in the impulse communicated 
to the general mass of the 
fcetus." 

The head, having accom- 
plished the movement of direct 
descent, and having cleared 
itself from the trammels of the 
cervix uteri, becomes again 
somewhat extended. But, as 
it thus presses on the smooth 
pelvic floor, the occiput very 
naturally glides in the direction 
of least resistance, flexion is 
again firm, and rotation of the 
head occurs, by means of which 
its long diameter moves from 
the right oblique to the conju- 
gate diameter of the pelvis, and 
the occiput slips under the 
pubic arch. 

The spines of the ischia have been said to act an important 
part in rotation, but we are inclined to deny them the title of 
"key to the mechanism of labor." Since it is always the most 
dependent part which rotates to the front, a moment's reflec- 
tion will enable us to see that rotation, therefore, takes place 
in such a direction that the sloping surface of the foetal head 
corresponds with the incline of the perineum. 

The law which controls the movement known as "rotation" 
is based upon the mechanical principle that, when a body is 
subjected to unequal pressure, its movement will always be in 
the direction of least resistance. Kotation is not always com- 




Fig. 179.— Showing the lateral 
obliquity of the Head with refer- 
ence to the horizon, in the pelvic 
cavity in the first position. 



406 



Labor. 



plete, the long diameter of the head still preserving some of its 
original obliquity. 

At the outlet there may be a certain amount of bi-parietal 
obliquity to the vulvar plane, and accordingly the right parietal 
eminence is born in advance of the left. The question of 
syn elitism of bi-parietal and pelvic planes merits but little 
study from any other than the specialist. 

Passage of the Head Through the Outlet. — Flexion at this 

part of labor should be firm, so as 

to bring the shorter diameters of 

the head into the strait. At the 

/ X same time the occiput glides under 

the pubic arch, and becomes the 
center of another movement which 
is now begun, namely, extension. 
The occiput being fixed under the 
arch, is prevented, by the nape of 
the neck, from further advance, and 
the direction of least resistance is 
changed, so that now the perineum 
is distended, and by the movement 
of extension alluded to, the head 
passes the vulva. 

Restitution, or External Rota- 
tion. — After birth of the head, a 
movement of accommodation, 
known as restitution, or external 
rotation, takes place, which is 
nothing more than the face turning 
in this case to the mother's right 
thigh. The change is effected mainly 
in deference to the shoulders, which 
are yet to be delivered, the long, or 
bisacromial, diameter of which now seeks the pelvic conjugate. 
This is an important movement. The long diameter of the 
vertex, and the long diameter of the shoulders, naturally 
assume directions at right angles to each other. In the 
first position, the vertex lies with its long axis in the right 
oblique diameter of the pelvis, and the bisacromial axis 
in a converse direction. During rotation of the head in 
the pelvic cavity, the position of the shoulders does not 
materially change, and after the head escapes, it forsakes 




Fig. 180.— B, short arm of 
head lever. B F, long arm of 
head lever. 



Mechanism of Labor. 



407 



its constrained position, and is restored to its original, or, at 
least, its recent direction,— hence the name of the movement, — 
restitution. But this does not complete the movement, for, no 
sooner has the head fairly escaped than the shoulders begin to 
adjust themselves to the outlet by turning their long diameter 
into the conjugate, and as this change occurs, the head is still 
further rotated, until the face looks pretty squarely to the 
mother's right thigh. 

While these are the usual phenomena, others are sometimes 




Fig. 181. — External rotation of the Head. 



observed to substitute them. It would occasionally appear 
that rotation of the shoulders does take place simultaneously 
with that of the head, in which case the bisacromial diameter 
comes to lie at the brim, or in the cavity, in a transverse direc- 
tion, and when the shoulders rotate, preparatory to escape 
from the outlet, it pursues the usual direction, and, as a result, 
the face is observed to turn towards the mother's left thigh. 
The author has seen many marked instances of this anomalous 
movement. 

The term restitution has by some been limited to the first 



408 



Labor. 



part of the external movement, while the balance is called ex- 
ternal rotation. The term external rotation may properly be 




Fig. 182. — The Head approaching the outlet in the first position. 

applied also to the anomalous movement just described, which 
is not strictly restitution. 




Fig. 183. — Illustrating the various movements of the Head in the first 
position of the Vertex. 

Expulsion of the Trunk.— After birth of the head there is 
generally a rest, and upon the renewal of pain, the right 
shoulder is directed forwards by the right anterior ischial plane, 



Mechanism of Labor. 



409 



while the left glides backwards over the left posterior plane, 
into the sacral hollow. This movement is often quite sudden, 
and is accomplished only as the part actually passes the vulva, 
which it must do with a spiral motion. The body is bent upon 
itself, and the left shoulder is driven downwards until it shows 
at the posterior commissure, when the right slips under the 
pubic arch, and finally both emerge almost simultaneously. 

If the arms are flexed, the elbows pass with a jerk, and some- 
times produce laceration of the perineum. The trunk easily 
follows the shoulders, and the entire body is speedily born. 

Mechanism of the 
Second, or Right Oc- 
cipito- Anterior, Posi- 
tion. — In the second 
position of the vertex 
the long diameter lies in 
the left oblique diameter 
of the pelvis, and the 
occiput looks forwards 
and to the right ilio- 
pectineal eminence, or 
acetabulum, and the 
forehead towards the 
left ilio-sacral synchon- 
drosis. The same gen- 
eral movements are 
performed, namely, de- 
scent, flexion, rotation, 
extension, and restitu- 
tion ; but the directions are changed from right to left, instead 
of left to right, and external rotation takes place by the face 
turning towards the mother's left thigh, instead of her right. 
The left shoulder rotates from the left side to the pubic arch, 
whereas, in the first position, the right shoulder rotates from 
the right side forwards. Further material differences than these 
do not exist, and we accordingly omit a detailed description of 
the mechanism of this position. 

Mechanism of the Occipito-posterior Positions. — The 
occipito-posterior positions are the third and fourth, in the 
former of which the occiput lies towards the right ilio-sacral 
synchondrosis, and in the latter to the left ilio-sacral synchon- 
drosis. The third position occupies the same oblique diameter 




Fig. 184. — Second position of the Vertex. 



410 



Labor. 




Fig. 185.— Third position of the Vertex. Fig. 186. — Fourth position of the Vertex. 




Fig. 187.— Showing proper rotation of the Head in the fourth position 

of the Vertex. 



Mechanism of Labor. 411 

as the first, and the fourth the same diameter as the second, 
but the poles are reversed. What creates particular interest in 
connection with these positions is the necessarily extensive 
rotation by which the occiput is brought to the pubic arch. In 
occipitoanterior positions, the rotation is short and easily 
accomplished, while in occipito-posterior positions it is long 
and difficult, the occiput sweeping around two-fifths of the 
circumference of the pelvic circle. Anomalous rotation oc- 
casionally takes place, in which case the occiput is thrown back- 
wards against the perineum. Such a case as that to which we 
have just adverted, wmerein the occiput persists in maintaining 
a backward direction, is more difficult and dangerous than an 
occipitoanterior termination, because the head has to be sub- 
jected to greater moulding, and, even then, its longer diameters 
are involved at the outlet. The occiput in such a case, after 
much effort, slips through the vulva, and rests upon the 
perineum, upon which, as a pivot, the head rotates in the move- 
ment of extension, until it ultimately passes. The movements 
described as taking place in the first position occur here also. 
Flexion is, or should be, firm; rotation should take place as 
described ; extension is observed at the vulva, and restitution 
occurs after head expulsion. 

When rotation is properly accomplished, the third becomes, 
as stated, the second, and the fourth, the first; from which 
point onwards their movements are identical. When labor termi- 
nates in an occipito-posterior position, the face of the child 
turns, in restitution, in the third position towards the mother's 
left thigh, and in the fourth, towards the right thigh. 

With regard to the causes which determine rotation for- 
ward of the occiput, the following experiments of Dubois will 
be instructive : "Ina woman who had died a short time before 
in childbed, the uterus, which had remained flaccid, and of 
large size, was opened to the cervical orifice, and held by aids in 
a suitable position above the superior strait; the foetus of the 
woman was then placed in the soft and dilated uterine orifice in 
the right occipito-posterior position. Several pupil-midwives, 
pushing the foetus from above, readily caused it to enter the 
cavity of the pelvis ; much greater effort was needed to make 
the head travel over the perineum and clear the vulva ; but it 
was not without astonishment that we saw, in three successive 
attempts, that when the head had traversed the external geni- 
tal organs, the occiput had turned to the right anterior posi- 



412 



Labor. 



tion, while the face had turned to the left and to the rear ; in a 
word, rotation had taken place as in natural labor. We re- 
peated the experiment a fourth time, but as the head cleared 
the vulva the occiput remained posterior. Then we took a 
dead-born foetus of the previous night, but of much larger size 
than the preceding ; we placed it in the same conditions as the 
first, and twice in succession witnessed the head clear the vulva 
after having executed the movement of rotation. Upon the 
third and following essays, delivery was accomplished without 




Fig. 188. — Occipito-posterior termination of the third position of the 

Vertex. 

the occurrence of rotation; thus the movement only ceased 
after the perineum and vulva had lost the resistance which had 
made it necessary, or, at least, had been the provoking cause 
of its accomplishment.'' 

High Rotation. — "Rotation," says Leishman, very truly, 
"at an early stage of labor, before it is yet practicable to as- 
certain the actual position of the head with anything like cer- 
tainty, is probably of much more frequent occurrence than we 
have any idea of. Few things are more familiar to the experi- 
enced accoucheur than a rotary or rolling movement of the 
head, which he observes either during a pain or an interval, 



Mechanism of Labor. 413 

while it is still high in the pelvis. This is due partly to uterine 
action, and partly to the movements of the foetus, and we have 
no doubt that, by this means, many unnatural and faulty 
positions are rectified even after labor has commenced ; and we 
are further entitled to assume that in this way many occipito- 
posterior positions are rectified at such a stage that their de- 
tection is rendered impossible. It should always be remembered 
that the dorso, or occipito-anterior, position of the child is the 
natural one, and that according to which the irregular oval 
which it forms is most conveniently disposed." 

Conversion of Occipito-posterior into Occipito-anterior 
Positions.— A very important question of treatment may not 
inappropriately be here considered, namely, the possibility, 
practicability, and advisability of converting occipito-posterior 
into occipito-anterior positions. The experience of ourselves, 
as well as others, thoroughly convinces us of the possibility of 
so doing. Whether, in all cases, it is advisable so to do is an- 
other matter. We believe, however, that when the head is still 
free above the superior strait it may nearly always be accom- 
plished by manipulation of the suitable kind. But sometimes, 
in order to accomplish it, the effort involves a certain amount 
of risk to the woman, which it is not always advisable to incur. 

Smellie, more than a century ago, executed such a change in 
a difficult case, and thereby accomplished a result which "gave 
him great joy." The feasibility of the operation is advocated 
by a goodly number of obstetricians of to-day. It is not an 
operation, however, which can be performed at every stage of 
labor, but the possibility of ifs successful execution is limited 
to two periods, namely, that of early labor, when the head is 
still free above the pelvic brim, and that part of the second 
stage, when the advancing occiput presses firmly on the pelvic 
floor. At no other time should it be attempted. Attention to 
the ordinary movements of the head will sometimes obviate 
any necessity for interference. In the process of descent there 
is sometimes manifested a tendency of the chin to leave the 
sternum, and the head to become extended. To allow this con- 
dition to persist, is to preclude the possibility of rotation for- 
ward of the occiput by the natural forces; while to enforce 
flexion is the only thing required to secure the desired end. In 
other cases, two fingers under the occiput, and slight traction 
in an anterior or lateral direction, during, as well as between 
pains, will bring about rotation. 



414 Labor. 

But again, while the head still lies above the brim, or but 
loosely engaged, it is deemed advisable to effect rotation. That 
being true, the forceps may be used, or not. Dr. Jno. S. Parry 
is a strong advocate of manual rotation in these positions. 
He recommends the introduction of the well-oiled hand into the 
vagina, and the fingers through the os uteri. The head is then 
grasped as firmly as possible, and rotation effected, while with 
the opposite hand, by external manipulation, the body is 
turned on its longitudinal axis. The range of applicability of 
such treatment should be left to the good judgment of each 
individual practitioner, as we are not prepared to commend so 
radical treatment as a routine practice. 

Scanzonrs Method of Changing Cranial Positions.— Dr. Aly, 
in presenting this subject before the Obstetrical Society at 
Hamburg, recently, contended that abuse of the operation 
brought it into discredit. He was of the opinion that a very . 
valuable method was being neglected, and, that in using it, 
Scanzoni's conditions and indications must be strictly observed. 
These are— 1. The operator must make an exact diagnosis of 
the position of the head. 2. The head must be deep in the 
pelvis and be well grasped by the forceps, with proper respect 
to any anomaly of the pelvis. 3. The mother or child must 
be in danger. This operation of Scanzoni consists in seizing 
the head with a pair of straight forceps, and effecting forci- 
ble rotation far enough to bring the occiput somewhat 
forward. Among German authors, Winckel does not men- 
tion it in his text-book; Spiegelberg warns against it, and 
Schroeder advised waiting till the head rotated, or extracting 
with the occiput posteriorly. In the discussion following, Dr. 
Lomer vehemently opposed the use of the forceps as an instru- 
ment for rotating the head. He had seen a healthy young 
woman lose her life in consequence of it. The very fact that 
all modern obstetrical teaching opposed it, showed that others 
had experienced similar results. When a large head is fixed in 
the pelvis, the amniotic fluid having escaped, the head becomes 
moulded and conforms to the shape of the pelvis ; rotation of 
the head with the forceps, under these conditions, will either 
fail or be attended with severe injury to the mother. If 
extracted without rotation, the most severe maternal injury 
will be a deep perineal laceration. If the head be small or the 
pelvis large, the head can be brought down to the floor of the 
pelvis in the ordinary manner with the forceps. It will then 



Mechanism of Labor. 415 

almost always rotate. If it should fail, Kitgen's method is to 
be employed. Prof. Olshausen expressed the opinion that only 
those possessing exceptional skill should attempt the method. 
He remarked that introduction of a single blade and using it 
generally as a lever, was often sufficient to rotate the head. 

We give this subject further consideration in the chapter 
treating of the use of the forceps in occipito-posterior positions. 

Caput Succedaneum.— This is the name of a swelling which 
forms on the foetal head during labor, resulting from effusion of 
serum or blood, or both, into the cranial coverings, or facial 
tissues. It does not form on the head of a dead child. 




Fig. 189.— Outline of foetal Head Fig. 190.— Outline of Head four 

after an ordinary labor, — Vertex days after birth, 
presentation. 

It develops on that part of the head that is subjected to the 
least pressure, and hence, at first, within the circle of the os 
uteri. As labor advances, the area is extended, and more or 
less modified. Development is most marked as the head is 
being driven through the pelvic canal. In the first and 
fourth positions it is found on the right, and in the second and 
third positions, on the left parietal bone. In occipito-anterior 
positions it is located more posteriorly than in occipito-poste- 
rior positions, owing to the shifted area of cranial exposure to 
diminished resistance ; while in face presentation it distorts and 
deforms the countenance. 

Configurations of the Head in Vertex Presentation — 
Since the cranium of the fetus is constructed of a number of 
bones, so articulated as to be capable of overlapping and 
moving under pressure, it follows that, in a close labor, this 
part undergoes a considerable amount of moulding, by means 



416 



Labor. 



of which its respective diameters are greatly modified. The 
smaller the parturient canal, the more difficult the labor, — the 
more extensive the change. 

The most important modification is diminution of the sub- 
occipito-bregmatic, the occipito-frontal and the bi-temporal 
diameters, with elongation of what is generally regarded as the 
occi pi to-mental diameter, but which is, more accurately, the 
diameter represented by a line drawn from the end of the chin 
to a point on the vertex between the anterior and posterior 
fontanelles, nearer the latter than the former. 

Under pressure the frontal and the 
occipital bones are depressed and 
slide beneath the parietal bones, while 
at the same time one parietal bone 
overlaps the other. Moreover, the 
parietal bones themselves are some- 
what changed in form, the cranial 
being curved at the point in front of 
the posterior fontanelle, hereinbefore 
alluded to, the sharpness of the curve 
being determined by the closeness of 
the labor, or, in other words, by the 
amount of compression exerted. When 
the head passes the outlet in an oc- 
ci pito-posterior position, the changes 
noted are still more marked. 
The outline of the head is further changed by the formation 
of the caput succedaneum. 

We may here add that the long-drawn-out appearance of the 
head which has been subjected to extreme moulding to make it 
conformable to the calibre of the parturient canal, in general 
soon passes away without the adoption of any special treat- 
ment to correct it ; but the change may be somewhat accele- 
rated, and, perhaps, rendered more pronounced, by gentle 
pressure upon the poles of the occipito-frontal diameter with 
the palms of the hands. 

Diagnosis of Position, etc.— This subject has been discussed 
in another place, and does not here require mention. 




Fig. 191.— Form of the 
Head in Vertex presenta- 
tion, after difficult labor. 



Mechanism of Labor. 417 



CHAPTER VII. 

THE MECHANISM OF LABOR.— Continued. 

Face Presentations.— The face constitutes the presenting 
part, according- to Hodge, once in about 250 cases, according 
to Spiegelberg, once in 324 cases ; according to Churchill, once 
in 231 cases; according to LaChapelle, once in 217 cases; and 
according to Depaul once in 175 cases. 

Character of Labor. — Labor in connection with face presen- 
tation, while it may, in quite a proportion of instances, be 
terminated by the natural efforts, is generally far more tedious 
and difficult than in vertex presentations, and often presents 
complications of a most formidable nature. This is particu- 
larly true, as will later be seen, in connection with mentoposte- 
rior positions. For these reasons, and the additional fact that 
it is a presentation in w T hich the dangers to both mother and 
child are considerably increased, we have thought best to adopt 
the classification which places it among abnormal presentations. 

Causes —There seems to be but little doubt that face pres- 
entations are most commonly transformed vertex presenta- 
tions. The movement by which the latter are converted into 
the former consists only in extension, and a variety of causes 
may operate to effect the change. Hecker attributes many 
cases of face presentation to unusual length of the head, and 
the theory appears to be a plausible one. Other causes of ex- 
tension are set down, as enlargement of the thyroid gland, 
increased size of the chest preventing sufficient flexion of the 
head, contraction of the pelvic brim, and unusual mobility of 
the foetus owing to its small dimensions. Winckel says that 
thirty -three different causes have been suggested. 

Lateral obliquity of the fcetus and long uterine axis, is sup- 
posed by many to be an important factor in the etiology of 
these presentations. Uterine action presses the head against 
the lateral boundary of the pelvic brim, and, favored by direc- 
tion of the occiput towards the side of the uterine deviation, 
tilts it backwards. Such a movement would be favored by 
dolichocephalia, as suggested by Hecker. When once extension 
passes the line of equipoise, the presentation becomes perma- 
nently established. Proper flexion of the head is sometimes 
prevented by the presence of a prolapsed extremity which en- 
(27) 



41 8 Labor. 

croaches on the pelvic space, and tends at last to displace the 
vertex from the pelvic brim. 

Relative Frequency of Positions. — Statistics are not yet 
sufficiently numerous to settle the question of the relative fre- 
quency of the various positions. There is doubtless but little 
difference in point of frequency between left and right dorsal 
positions. Naegele considered the first as the most frequent, in 
the ratio of twenty-two to seventeen. Tyler Smith said that 
the third and fourth facial positions are so extremely rare as 
hardly to be worth enumerating'. There is, however, quite a 
lack of, harmony among obstetric writers, for Leishman and 
others proclaim the fourth position as the most frequent, while 
Charpentier unites with Naegele in putting L. M. A. in advance. 
It is by no means rare for the face to enter the pelvis with its 
long diameter lying transversely. 

Mechanism of the First Position of the Face. — In the 
first position of the face the occipito-mental diameter lies in the 
right oblique of the pelvis, and the chin is directed to the right 
sacro-iliac synchondrosis. 

For descriptive purposes we may divide the mechanism of 
face presentations into the movements which follow : 

First movements, — descent and extension. 

Second movement, — rotation. 

Third movement, — flexion. 

Fourth movements, — restitution and external rotation. 
These we shall proceed to consider in the order of their 
occurrence in the first, or right mento-posterior, position. 

Descent and Extension. — These two movements, because of 
their almost simultaneous occurrence, are here described to- 
gether, as were descent and flexion in vertex presentations. So 
far as the mechanism of labor is concerned, the chin in face 
presentation corresponds to the occiput in vertex presentation, 
and hence, in well marked instances of the former, we find the 
chin sinking lower and lower in the cavity, thereby greatly 
augmenting cephalic extension. The degree of extension is 
ascertained by the relative situation of the chin and anterior 
fontanelle, both of which can sometimes be reached. The head 
engages the superior strait against mechanical disadvantages, 
and hence slowly. The degree of descent which can be accom- 
plished with some degree of facility is determined by the length 
of the child's neck, unless the thorax and shoulders chance to 
be small enough to pass into the pelvic cavity. 



Mechanism of Labor. 



419 



The chin maintains its advanced position, owing to a 
mechanism similar to that which causes the occiput to take the 
most advanced position in vertex presentation. The fronto- 
mental diameter represents a lever with the short arm on the 
mental side, and the long arm on the frontal side. Propulsive 
force is applied from above, and of course the short arm is 
forced downwards. 

Rotation. — The exact amount of descent which the length of 
the neck will permit in these cases, depends upon circumstances. 

Observation teaches that, in most cases, the shoulders 
do not reach the brim, and engage it, until after the face 




Fig. 192. — Face presentation at the outlet,— mento- posterior position. 

presses on the perineum. Farther descent is impeded, and ro- 
tation forward of the chin seems to be a necessity. In nearly 
all cases the movement does take place in a natural manner, 
and menacing dangers are thereby averted. The chin in face 
presentations, and the occiput in vertex presentations, in the 
movement of rotation, act in obedience to a similar mechanism. 
The chin, being in advance, first comes in contact with resist- 
ance at the pelvic floor, and acting under the well-known law 
of mechanics that a body subjected to varied degrees of press- 
ure moves in the direction of least pressure, turns forwards, 
while the cranial vault seeks the pelvic floor. 

In the course of rotation there is a complete change of posi- 
tion, the first becoming the fourth. By means of rotation the 



420 



Labor. 



chin is brought to the pubic arch, and expulsion thereby 
facilitated. 

Abnormal Mechanism. — In a small percentage of cases, the 
chin, instead of pushing forwards to the pubic arch, moves back- 
wards into the sacral hollow, and labor terminates as repre- 
sented in figure 198. The effect of this is excessive stretching 
of the neck of the foetus and vulvar structures of the woman. 
Unless the child prove to be relatively small, labor can scarcely 
be determined without artificial aid. 




Fig. 193. — Engagement of the Head in face presentation. (Tarnier et 

Chantreuil.) 

The depth of the pelvis posteriorly, and the added length of 
the perineum, will not admit of descent of the chin over the 
posterior vulvar commissure without a surprising amount of 
cranial flattening, aud entrance of the thorax to a certain 
extent into the pelvic cavity. Cases have occurred in which, from 
unusual smallness of the head, distension of the sacro-sciatic 
ligaments has permitted flexion to take place, and delivery thus 
spontaneously to be effected. 

Flexion. — In face presentation, with the chin to the pubic 
arch, the movement by which the head passes the vulva is one 



Mechanism of Labor. 



421 



of flexion. The chin engages under the pubic arch and remains 
fixed, while the forehead, vertex and occiput, successively sweep 
over the distended perineum. 

Restitution. — Then occurs the final movement, that of resti- 
tution, or external rotation, the face in the first position 
turning towards the mother's right thigh. The shoulders 
follow, and expulsion is speedily accomplished. 

Form of the Cranium in Face Presentation.— As a result 
of excessive compression of the head in so unnatural a posi- 
tion, the cranial vault is considerably flattened. The trans- 




Fig. 194. — Showing proper rotation of the Head in the second position of 

the face. 

verse, the occipito-frontal, and especially the occipito-mental 
diameters, are consequently increased, while the sub-occipito- 
bregmatic is diminished. Tumefaction of the presenting area 
is liable to be excessive, so that the foetal countenance immedi- 
ately after birth presents an appearance scarcely human. 
Swelling is greatest in the malar region, because the early 
presenting area is usually found within it. 

Prognosis. — We have before alluded to the augmented 
danger to both mother and child in this variety of presenta- 
tion. Winckel gives the mortality of the foetuses in face pre- 
sentation at thirteen percent., and Parvin at fifteen. Mortality 



422 Labor. 

of the mothers is at least two or three fold that associated with 
vertex presentation. The average duration of labor exceeds 
that in vertex presentation, while protraction is attended with 
more dangerous consequences, and demands, with greater 
urgency and frequency the aid of obstetric resources. 

The Second Position.— The mechanism of the second posi- 
tion is quite like that of the first, except that the directions are 
changed. Rotation takes place by the chin swinging around 
from the left ilio-sacral synchondrosis to the pubic arch. In 
making the movement the second rotates into the third posi- 
tion, from which point onwards the mechanism is essentially 
that of the third. 

Third and Fourth Positions.— The first and second are 
recognized as unfavorable positions, because the chin is directed 
backwards, and the necessary rotation is extensive. The third 
and fourth positions are favorable, because they are mento- 
anterior positions, and the necessary rotation is but slight. In 
the latter, the chin, in its descent, strikes against one of the 
anterior inclined planes, and is directed forwards under the 
pubic arch; while in the former, even though the chin does 
usually rotate anteriorly, much delay and difficulty are often 
experienced. A backward rotation of the chin gives a termi- 
nation of the most unfavorable description. 

A special detailed account of the mechanism of labor in the 
third and fourth positions is not required, as it differs not at 
all from that of the second and first positions, respectively, 
after partial rotation has taken place. 

Treatment.— The older obstetricians looked upon presen- 
tations of the face as not only abnormal, but as always 
demanding artificial assistance; the treatment being version, 
when practicable, and instrumental delivery in neglected cases. 
Later practice is more discriminative. 

An important concern of treatment is to preserve intact, 
throughout the first stage, the bag of waters. This is here a 
matter of more importance than in vertex presentation, because 
of the irregularity of the presenting part, and the likelihood 
of complete escape of the liquor amnii should rupture take 
place. 

Conversion of Face into Vertex Presentations.— This is 
a matter worthy the closest attention. The manipulations 
generally recommended are pushing up the face, or drawing down 
the occiput, by means of the hand passed into the vaginal 



Mechanism of Labor. 423 

and cervical canal. Still, the suggestion has not commonly 
been acted upon, owing to the difficulties and dangers accom- 
panying it. That it may be done without much effort in 
favorable cases, the author has, from experience, become con- 
vinced. 

But it must not be supposed that the demand for interfer- 
ence is laid with equal emphasis on every case. When the face 
presents in the first or second position, we have an unfavorable 
condition. In other words, we have an adverse position of an 
adverse presentation, and b} 7 flexing the head we convert the 
case into a desirable position (occipitoanterior) of a desirable 
presentation, and the measure of advantage to be derived from 
the change more than compensates for considerable effort and 
risk. On the other hand, the third and fourth positions of the 
face are favorable positions of an unfavorable presentation, 
and by flexing the head they are converted into an adverse po- 
sition (occipito-posterior) of a friendly presentation, and we 
would not be justified in assuming the risk of a protracted or 
difficult manipulation. 

No attempt to change the presentation should be undertaken 
after the head fairly engages the brim, unless delivery by any 
other method seems impracticable, as the occipito-mental 
diameter of the standard foetal head exceeds every pelvic diam- 
eter, and incarceration would be likely to result. 

In occasional instances the head can be dislodged by firm 
pressure, even after a certain degree of descent has taken place, 
and then it will be managed as in those cases where no descent 
has been made. 

Whenever such manual operations are undertaken, the 
woman should be put under the relaxing influence of an anes- 
thetic. 

The following method of manipulation, suggested by Schatz, 
is one of the best. It is based on the assumption that, if the 
body be restored to its normal attitude, by flexing the trunk 
the head will drop into its normal position at the brim of the 
pelvis. To operate thus, we should seize the shoulder and 
breast through the abdommal wall, and lift them upwards, and 
at the same time backwards, while, with the opposite hand, we 
steady the breach so as to make the long fcetal axis correspond 
to the uterine axis. Finally, the breach and thorax are made 
to approach by downward pressure on the former. 

liaising the body, as described, gives the occiput an opportu- 



424 



Labor. 



nity to descend, and flexion of the foetal body, accompanied by 
backward and upward pressure on the chest, produces flexion 
of the head. Schatz says that when the head lies high, any 
attempt to enforce flexion by repression of the thorax, some- 
times causes movement of the whole head, for want of resist- 
ance, and, in such cases, the place of the pelvic wall may be 
supplied by pressure of the hand agaiust the head through the 
abdominal wall. The conditions friendly to the practice of this 
manceuver are skill in palpation, and the absence of abdominal 
and uterine irritability. We recently succeeded with this oper- 
ation in a case where the liquor amnii had been drawn off six 




«-€? 




Figs. 195, 196 and 197. — Diagrams illustrating Schatz's method of 
converting Face into Vertex presentations. 

hours, and the face had engaged the brim. The child lived, and 
the mother made an excellent recovery. 

Management When the Face Does Not Enter the Brim.— 
When the face refuses to pass the superior strait, operative 
interference is imperatively demanded. It will be understood 
as unwise practice to await such effort without making a 
strenuous attempt to convert the case into a vertex presenta- 
tion ; but such efforts may occasionally fail. 

Inability of the head, thus extended, to pass the brim, puts 
the case in this , category. The character of the aid to be 
given will be determined by the circumstances of the case. 
The head may be flexed by Schatz's method, or by introduction 
of the hand into the vagina and cervix, and the face thereby 
converted into a vertex presentation ; or podalic version maybe 



Mechanism of Labor. 



425 



practiced. In either case, internal manipulation should be 
aided by dexterous external use of the opposite hand. Appli- 
cation of the forceps to the face at the brim, is, in the main, 
impracticable and hazardous, as the blades cannot well be 
applied to the sides of the head, and to seize the face over the 
poles of its long diameter is extremely dangerous to foetal life, 
owing to pressure of one blade on the throat, and compression 
of the large vessels and nerves of the part. 

Persistent Mento-Posterior Positions.— Tardy rotation 
appears to be characteristic of face presentation, and a fair 
opportunity to effect the movement should be given the natural 
forces. The mechanical condition most favorable to forward 
rotation of the chin is here firm extension, and by maintaining 
it we greatly augment the proba- 
bility of proper rotation. The 
movement maybe aided to a cer- 
tain extent by suitably-directed 
pressure against the forehead. 
If these simple methods prove 
ineffectual, the forceps should be 
applied, and the head carefully 
turned in the direction which it 
should take. If the long curved 
forceps be used, they svill require 
removal and reapplication for 
completion of the movement, in 
order to avoid inversion of the 

instrumental curve and possible injury of the soft tissues. 
Every effort to bring forward the chin should be attempted 
during a pain, but only after the head has evidently cleared the 
pelvic brim. 

Very strong support of the perineum, while favorable to 
preservation of that part, is dangerous to the child, from 
pressure of the neck against the pubic arch. 

Brow Presentation.— When only partial extension takes 
place, the brow becomes the presenting part. Such presenta- 
tions must always be looked upon as of a most unfavorable 
nature, since the diameter presented is the longest of the 
cranium. Four positions are given, but, as the presentation is 
exceedingly rare, and generally becomes transformed into either 
a face or a vertex presentation, we shall not here describe them. 
If the head be small, and the pelvis roomy, labor may be 




Fig. 198.— Mento-posterior 
termination of Labor. 



426 



Labor. 



finished without unusual difficulty or injury either to mother or 
child. The head emerges from the vulva through firm pressure 
of the cranial vault on the perineum, while the upper jaw, the 
mouth, and finally the chin, slip under the pubic arch. 

Treatment of Brow Presentation.— Treatment consists 

first in attempts to con- 
vert the presentation in- 
to one either of the face 
or the vertex. Baude- 
locque's method of doing 
this involves introduc- 
tion of the whole hand, a 
thing to be avoided if pos- 
sible. Schatz's method 
of operating in face pres- 
entation may here serve 
equally well. The con- 
joint manipulation, one 
hand externally, and the 
fingers of the other hand in the vagina, is sometimes success- 
fully employed. Schatz recommended the introduction of two 
fingers into the child's mouth, and traction on the superior 
maxilla, for the production of a face presentation. It has not 
been our misfortune to encounter a case of brow presentation 
which could not readily be converted into a vertex presentation. 




Fig. 199. — Outline of Head, — brow 
presentation. (Budin.) 



Mechanism of Labor. 42' 



CHAPTER VIII. 

THE MECHANISM OF LABOR— Continued. 

Pelvic Presentations.— Under the general designation 
"pelvic presentation" are included all those cases where the 
pelvis precedes the trunk and head of the child in labor. Pelvic 
presentations are divided into those of the breech, knees and 
feet; but the mechanism of labor is in all these substantially 
one. 

Frequency of Occurrence. — Pelvic presentation is met 
once in about 47 mature births, while in premature labor and 
miscarriage it is of common occurrence. Footling presenta- 
tion is met once in about 100 cases. 

Prognosis. — While labor in these presentations is not unusu- 
ally dangerous to the mother, the perils of the child are greatly 
augmented. The foetal mortality in breech presentations is in 
the proportion of about 1 death in 4 cases, and in footling 
presentations, 1 death in 3 cases. The following comparative 
statistics of the Baden maternity are instructive: 



In 1883, forceps. 


Mortality : 


mothers, 


1.97%; 


infants, 


12.76% 


" " breech extractions. 


it 


" 


2.49%; 


" 




35.02% 


" 1884, forceps. 


" 


" 


1-05%; 


" 




10.8% 


" " breech extractions. 


a 


M 


1-07%; 


" 




23.05% 


" 1885. forceps. 


a 


" 


1.04% ; 


" 




9.08% 


" " breech extractions. 


" 


It 


1-02%; 


" 




2500% 



Pelvic presentations in primipara? are followed by an ex- 
tremely heavy foetal mortality. Robertson says of footling cases, 
"I do not remember having saved the life of a child, when the 
feet, in a first labor, formed the presentation." Danger to 
the mother, in pelvic presentation, is but slightly increased. 

Causes of Infantile Mortality.— The chief element of dan- 
ger in these cases is interruption of foetal circulation by com- 
pression of the cord. The foetus may be destroyed by asphyxia, 
arising also from another cause, namely, premature separation 
of the placenta, followed by prenatal attempts of the foetus to 
respire. Compression of the funis is rarely strong enough se- 
riously to interfere with foetal circulation, until the pelvis, and 
most of the trunk, have passed the vulva, and the bony 
cranium presses the umbilical vessels against the pelvic walls. 

Separation of the placenta takes place in these cases, as it 



428 



Labor. 



does in all others, as a result of the decided condensation of the 
uterus, but the action in head-last cases proves premature 
owing to delay in completing the delivery. Delayed birth of the 
head is occasioned by insufficient dilatation of the soft parts, 
the trunk not requiring for its passage as great expansion of 
the os uteri and vulva as does the head. 

Danger to the child is not confined to the moment when the 
head lies at the brim, but compression of the cord may take 
place at a later period, and premature separation of the pla- 
centa is more likely to be effected after the head descends into 




Fig. 200. — Movements of the Breech in first position. 

the pelvic cavity, but refuses to pass the vulva. Foetal circu- 
lation is interrupted, and respiration is impossible, as a result 
of which death from asphyxia soon ensues. 

Etiology of Pelvic Presentations. — It was supposed by 
the older physicians, that the foetus sat upright in the womb 
until the sixth or seventh month, at which time there generally 
occurred a sudden evolution, as the result of which the cephalic 
extremity became the presenting part. Failure to effect this 
movement explained the occurrence of pelvic presentation. 

There is no doubt that breech presentation is sometimes the 
result of a peculiarity in the conformation of the uterus. 
Velpeau mentions the case of a woman who, probably from 



Mechanism of Labor, 



429 



such cause, had six consecutive breech deliveries. Pelvic 
deformity is also a causative factor. In a case reported by Dr. 
'Randolph Winslow, a colored woman, with a deformity of the 
pelvic brim, had ten children, every one of whom presented by 
the breech. 

Diagnosis.— Nothing need here be said with reference to 
diagnosis, as the matter has been fully discussed elsewhere. 

The Mechanism of Breech Presentations in the First 
and Second Positions.— The first position of the breech is also 
known as the left dorso-anterior position, and is one of the 




Fig. 201. — Expulsion of the Trunk in breech presentation. 

most favorable. The soft and easily moulded breech, preceded 
or not by the bag of waters, driven into the os uteri, as readily 
dilates that part as does the head. 

Descent.— After the os has expanded sufficiently wide to 
permit the breech to pass, it gradually sinks, under forcible pro- 
pulsive action, to the pelvic floor, and approaches the vulva. 
Descent is usually slow, but dilatation of the os uteri and 
vagina is not required to be great in order that the trunk may 
proceed on its way. 

Rotation. — There is no extensive rotation in the pelvic 
cavity associated with breech presentation. In the first posi- 



430 



Lab ok. 



tion, the left trochanter lies forwards and to the right, and, in 
rotation, it turns from the right side to the pubic arch. In the 
second position the right trochanter lies forwards and to the 
left, and, in rotation, it merely comes to the pubic arch. These 
are both dorso-anterior positions. In the third position, the 
right trochanter lies forwards and to the right, and in the 
fourth the left trochanter lies forwards and to the left. Rota- 
tion in the former position is from right to left, and in the latter 
from left to right; but in no case is the traversed distance 

extensive. Then, too, 
rotation, insignificant 
as it is, does not often 
take place until the 
nates have pushed 
through the vulva, and 
is completed only when 
the trunk has nearly 
passed. 

From inattention to 
the proper manage- 
ment of dorso-posteri- 
or positions, the after- 
coming head may be 
permitted to descend 
and enter the pelvis in 
an occipito - posteri or 
position, in which case 
cephalic rotation, un- 
der unfavorable condi- 
tions, becomes neces- 
sary. 

Expulsion— The anterior natis makes its appearance at the 
vulva, and the posterior pushes over the perineum. The anterior 
trochanter finds a point of support under the pubic arch until 
the opposite trochanter passes, when both descend/ in a for- 
ward direction, necessitating considerable flexion of the body 
in the pelvic canal. As the trunk passes, it is well to have the 
fingers at the vulva to hook down the arms, which are prone to 
be thrown upwards. The anterior shoulder rests under the 
pubic arch until the posterior passes, after which the head alone 
remains within the vaginal embrace. 

The head engages the brim in an oblique diameter, and 




Fig. 202. — Delivery of Posterior Arm in 
Head-last cases. (Zweifel.) 



Mechanism of Labor. 



431 



usually with the chin upou the sternum. The inclined planes 
turn the occiput forwards as the head descends. The neck rests 
in the pubic arch, and serves as a center of motion, and as the 
body is raised by the accoucheur, the face and sinciput pass 
the distended perineum, thereby completing the second stage. 

The Mechanism of Breech Presentation in the Third 
and Fourth Positions— So far as the trunk and extremities 
are concerned, there is little difference between the mechanism 
of clorso-anterior and that of dorso-posterior positions. The 
chief particular in which they differ has reference to the after- 
coming head. After expulsion of the trunk of the foetus, we are 
apt to find, in neglected 
cases, that the head en- 
gages the brim with the 
occiput directed to one 
ilio-sacral synchondrosis 
or the other, and, in order 
to secure a desirable ter- 
mination of the labor, 
extensive rotation in the 
pelvic cavity is neces- 
sitated, which, by the 
way, is often attended 
with much difficulty . This 
is a complication which 
can usually be obviated 
by proper attention to 
the body in its descent 
through the outlet. When 
the trunk and shoulders are of usual size, there is seldom any 
necessity for close approach of the bisacromial diameter to the 
pelvic conjugate, at the outlet. Bearing in mind this fact, if we 
will rotate the trunk on its longitudinal axis during the mo- 
ment of its expulsion, the head also, which lies perfectly free 
above the brim, will rotate, in compliance with the suggestion 
thus offered, and as a consequence, this part enters the brim in 
an occipitoanterior position. The rotation here advised should 
be neither rapid nor forcible; though we are often obliged to 
accelerate the movement to a certain extent, on account of the 
rapid progress of expulsion. 

In those cases wherein, from a combination of circumstances 
beyond the physician's control, the head enters the brim in an 




Fig. 203.— Third position of the Breech. 



432 



Labor. 



occipito-posterior position, if traction is not applied to the 
trunk, the condition of head flexion will usually be maintained 
by the contracting uterus, and rotation will take place in re- 
sponse to slight suggestions from the lingers of the accoucheur. 
But this movement, and that also of final expulsion, depends 
to a very great extent on thorough flexion of the head on the 
breast, and the accoucheur ought to enforce this attitude by 

proper manipulation. 
The trunk of the child, 
wrapped in a towel, 
should rest upon the 
most convenient arm, 
while the fingers of the 
same hand are passed 
into the vagina, as far 
as the child's face. 
Pressure and traction 
should then be made 
with the fingers in the 
canine fossa?, while at 
the same time the fin- 
gers of the opposite 
hand exert upward 
and backward pressure 
on the occiput, and the 
body is carried well 
forwards, as in all 
cases of pelvic presen- 
tation, until the head 
passes. If the fossae 
caninse cannot at first 
be reached, the fingers 
may be passed into the 
mouth, and moderate 
flexion force applied to the inferior maxilla until such time as 
a higher point can be reached. 

In some cases it will be found impossible to bring forward 
the occiput, and labor must terminate with the occiput to the 
perineum, and the face to the pubes. There is then the same 
necessity as at other times for firm flexion of the head, but 
while enforcing it in the manner already described, the body 




Fig. 204. 



-Delivery of the After-coming 
Head. 



Mechanism of Labor. 



433 



should be carried backwards, instead of forwards, until the 
neck rests on the posterior vulvar commissure, w T hen the face 
revolves about it as a center, and in so doing glides under the 
pubic arch. 

Footling Presentation.— It is unnecessary to give a de- 
tailed account of footling presentation, since the mechanism 
and management of it agrees in all essential particulars with 
those of breech presentation. Rotation is delayed until the 
breech reaches the outlet. The head is delivered with greater 
difficulty than in 
breech presentation, 
since the foetus, when 
extended, resembles 
the form of a wedge, 
w T hich in footling cases 
passes the pelvis with 
its small end in ad- 
vance. 

Treatment of the 
Arms . — Ordinarily, 
the physician experi- 
ences some trouble in 
bringing down the 
arms when they are 
extended upwards by 
the side of the head, 
and occasionally the 
m a uceuvre is per- 
formed with the great- 
est difficulty. The 
fingers of the oper- 
ator should be passed 
under the pubic arch, and over the anterior shoulder, when one 
arm at a time can be made to descend along the anterior sur- 
face of the child. 

Breathing Space for the Foetus in Case of Pelvic Presentation. 
— When the head cannot at once be delivered from the pelvic 
cavity, and the child is endeavoring to inflate its lungs, the 
mouth should be drawn well down to the perineum, wmere air 
can be admitted to the foetus by inserting two fingers and 
making forcible retraction of the perineum and recto-vaginal 
septum. This is a fertile expedient for saving foetal life. 

(28) 




Fig. 205. — The Forceps applied to the after- 
coming Head. (Zweifel.) 



434 



Labor. 



Difficult Extraction of the After-coming Head. — The obser- 
vations which follow have reference to difficult extraction of 
the head when it lies in the pelvic cavity, and must not be 
understood as applicable to those cases of difficult head-last 
cases wherein the obstacle to facial delivery lies in contraction 
of the pelvic brim . 

The ordinary measures which suffice for a goodly percentage 
of pelvic cases are sometimes found insufficient for speedy 
extraction of the retained head, and rescue of the foetus from 
impending danger demands a resort to some more efficient 
expedient without unnecessary waste of time. When the occiput 
is turned towards the pubic arch, an expedient of great 

efficiency is found in 
forcible traction at 
right angles to the wo- 
man's body. Properly 
to secure this necessi- 
tates a position high 
above the patient, 
such as can be secured 
by standing upon the 
bed, when, by getting 
a firm hold of the 
child's feet through the 
intervention of a tow- 
el, the necessary trac- 
tion can be applied. 
By drawing on the 
body in this direction 
the occiput is forced firmly against the pubic arch, and the 
resistance there encountered produces direct flexion of the 
head, thereby favoring safe exit from the vulva. 

The amount of traction which may thus be safely applied 
cannot easily be determined. Dr. Goodell believes that he has 
put on one hundred pounds and delivered a living child, and in 
two instances we must have exerted nearly as much traction 
without injury. 

If this sort of treatment avails without the loss of valuable 
time, it is well ; but if it avails not, then resort must be at once 
had to the forceps. In order properly to apply the instrument, 
the foetal trunk should be drawn quickly forwards, and there 
held while the blades are introduced. It goes without saying 




Fig. 206.— Shape of the Head in Breech 
presentation. C B, bi-parietal diameter. 
F, occipito-frontal diameter. 



Mechanism of Labor. 435 

that in these cases the operation should be done with the 
utmost dispatch compatible with safety. 

Configuration of the Head in Pelvic Delivery.— The 
absence of long-continued compression of the head in pelvic 
presentation, leaves the part in a shape which differs greatly 
from that observed in vertex and face cases. Instead of the 
long-drawn-out appearance given it when the vertex is in ad- 
vance, we have a characteristic roundness, due in part, as is be- 
lieved, to its circumferential compression by the pelvic canal, 
while absence of decided resistance above increases the convex- 
ity of the cranial vault. Still, the shape of the head usually 
observed after deliveries in which the breech or feet constituted 
the presentation, probably approximates the original form of 
the part. 

Management of Pelvic Presentations.— The practice of 
Hippocrates and his followers, of converting breech into 
cephalic presentations, was succeeded by that of bringing down 
the feet. The latter mode of treatment is now regarded as not 
only undesirable, but, under ordinary circumstances, unwar- 
rantable. We should not make a breech case still less auspi- 
cious by converting it into a footling presentation. If the 
labor is proceeding but slowly, the temptation may be strong 
to provide ourselves with a part upon which to make traction, 
and hasten delivery. But the wise man withholds his hand. 
After expulsion has gone so far that the trunk of the foetus is 
partly born, we may feel a strong impulse to seize upon it and 
hasten the labor. But such interference with the natural 
phenomena and mechanism of pelvic presentations is liable to 
involve us in a labyrinth of troubles, not the least vexing of 
which are extension of the arms above the head, and a separa- 
tion of the chin from the breast with its lodgment above the 
pelvic brim. When any traction effort whatever is made, it 
should be carefully done, and must be supplemented by abdom- 
inal pressure. 

Cephalic Version Before Labor. — There is a growing convic- 
tion among obstetricians, which has been strengthened in our 
school of practice by late contributions to the literature of the 
subject from the pens of Drs. R. N. Foster and G. R. South wick, 
that the proper management of breech presentation consists, 
in suitable cases, in conversion of the presentation into one of 
the vertex before the advent of labor. After relating a typical 
case, Dr. Foster makes the following points : 



436 



Labor. 



"First, that a breech presentation can be converted, some- 
times certainly, into one immensely preferable, at least two 
months before full term. The danger of delay is thus avoided, 
such danger being first that the waters may be discharged be- 
fore labor has commenced, and then change of position may be 
impossible; and secondly, that the increased size of the foetus 
and the sinking down of the uterus, so that the breech is deeply 
engaged, may render version impossible even if the waters are 
retained. In such cases as the one here related, version secures 
a living child instead of a dead one. This is affirmed on the 
ground of the second instructive point in the case, which is 

this : So far as can be dis- 
cerned,- there is but one rea- 
son for the very bad results 
of a breech presentation in 
the case of this mother; 
that reason is the peculiar 
shape of head which pre- 
vails in this family, alike 
in the father and in the 
mother. 

" Obstetricians have long 
recognized the two varieties 
of head known as the 'do- 
licho-kephalic' and ' brachy- 
kephalic,' or in plain Eng- 
lish the 'long-heads' and 
the ' short-heads.' But this 
division is incomplete. The 
family head in this house- 




Fig. 207. — Second position of the 
Breech, which is a little below the 
brim of the pelvis. 



hold is neither long nor short, but it is exceedingly broad ; and 
it is this diameter, the bi-parietal, which presenting as it does 
to the shortest diameters of the pelvis both at the brim and at 
the outlet, constitutes in just such cases the most formidable 
obstacle to a rapid delivery of the after-coming head. It also 
endangers most effectively the circulation of the funis, from the 
moment the head reaches the brim until complete delivery. 
This style of head ought by analogy to be called the ' platy- 
kephalic,' or 'broad-head.' 

"Now, given a well ossified skull, a male child, and a platy- 
kephalic cranium, together with a woman who will always 
present her children by the breech, and we have the precise com- 



Mechanism of Labor. 



437 



bination necessary to explain the foetal mortality in this 
family. 

"And finally, so far as one case can be said to illustrate a 
principle in such matters, the experience here recorded shows 
the possible value of attempting version at a much earlier 
period than that usually advised." 

Dr. Southwick presents the subject in a comprehensive and 
convincing manner, furnishes some good cuts which are herein 
reproduced, and enters into a detailed description of the 
operation. 

It gives us great pleasure 
to quote at length from his 
article. " On account of my 
own experience," he says, 
"and from careful observa- 
tion of the experience of 
others, I have sought for a 
remedy for cases likely to be 
difficult, and believe I have 
found it in version by ab- 
dominal and vaginal ma- 
nipulation about two weeks 
previous to labor, though 
I have performed it success- 
fully five weeks before labor. 
I have found the operation, 
as I perform it, to be very 
easy, requiring from five to 
ten minutes. It is painless, 
and I manage to talk with 
the patient, so that she is 
scarcely aware of what is 
being done. Indeed, she would not observe more than that she 
was being examined with some manipulation. 

"The preparations are identical with those for external ver- 
sion, a method which I have used with some success if the 
patient was not corpulent. I have found that the presenting 
part is apt to catch on the side of the pelvis (Fig. 207), requir- 
ing considerable effort to dislodge it, which was not always 
successful. 

"In order to meet this difficulty the writer now operates in 
the following manner, and will say here that while he is not 




Fig. 208. — Breech raised above the 
brim of the pelvis. Position of the 
External and Internal Hands iia press- 
ing the breech to one side of the pelvis. 



438 



Labor. 



aware that any other physician operates in this way, or that 
there is a published account of it, no doubt there are many 
obstetricians perfectly familiar with the details. 

"I first direct the patient to lie on her back in bed, un- 
dressed, in order to relax the abdominal muscles, with the 
knees drawn close up to the body and the shoulders and head 
well raised on pillows. I then thoroughly disinfect my hands 
and introduce the first and second fingers into the vagina, 
taking care not to enter the cervical canal. My first step is to 
gently press up the breech through the walls of the cervix, so as 

to raise the breech up just 
above the pelvic brim, and, 
if practicable, towards one 
side of the brim, correspond- 
ing to the back of the child 
(Fig. 208). Holding the 
breech in this position with 
the internal hand, I apply 
the fingers externally to one 
side of the breech and easily 
coax it to one side of the 
abdomen, corresponding 
with the back of the child, 
so that it will be in the posi- 
tion in Fig. 210, hands ex- 
cepted. The head will move 
down correspondingly on 
the other side, and the ex- 
ternal hand can now coax 
it with a little sliding pres- 
sure into the brim of the 
pelvis and by occasionally 
pushing up the breech (Fig. 209). Should the head stick a 
little after the breech is pressed well to one side of the pelvis, 
the left hand must keep its position and hold the breech to one 
side, as it always tends to slip back, and the right hand is 
taken from the vagina and applied to the head of the child, as 
in Fig. 210. By pressing gently up on the breech and down 
on the head, version is easily and painlessly accomplished. 
All manipulation is to be avoided during uterine contractions, 
which are recognized by feeling the uterine muscle harden at 
intervals. The patient must relax her muscles as much as 




Fig. 209.— Position of the hands in 
performing Vagino-abdominal Version 
after the breech has been raised and 
pressed to one side of the pelvis. 



Mechanism of Labor. 



439 



possible, and nothing is better to do this than to make her 
talk. It is easier to manipulate through thin abdominal walls 
than if they are very fat. 

'• There is another way of performing this simple operation, 
which appears better theoretically ; but I have not employed it 
for this particular form of version, as it is more trying to the 
patient than the former method, which is so simple. 

" The principle is the same, only the patient is placed on that 
side corresponding to the child's feet. The operator stands 
behind her, introduces the hand nearest the genitals, presses 
up the breech through the cervix as before, and the head by 
force of gravity drops down 
as the breech goes up, till 
the child is nearly in a trans- 
verse position, when the 
head is pressed down as be- 
fore. 

"The question naturally 
arises, will the infant remain 
in its new position, and, in 
view of the child moving 
about and naturally chang- 
ing its positionin the uterus, 
when would be the best time 
to perform version ? 

" In regard to the first 
question, I have kept the 
child in position by a couple 
of small folded towels on 
each side of the lower part 
of the uterus, which are se- 
cured by a moderately firm 
binder. In from twenty-four to forty-eight hours the uterus 
and child accommodate themselves to each other and the 
binder is unnecessary. 

"The child often changesits positionin pregnancy ; but in the 
last month it is rare for any pronounced change to take place, 
such as the substitution of a vertex for a breech presentation, 
or yice versa. I am of the opinion that about two weeks 
before the probable date of delivery is the best time to perform 
version. With the careful manipulation as described above it 
is difficult to imagine hoAv any harm could follow. It would 




Fig. 210.— Method of performing 
External Version after displacement 
of the breech, if that shown in Fig. 
209 proves insufficient. 



440 



Labor. 



be possible for a careless operator to allow his finger to slip 
into the cervical canal and rupture the membranes. This 
would cause labor, which ought to be perfectly natural, 
though possibly more prolonged than if a fortnight later at 
full term. 

"The head brought down to the brim simply substitutes a 
much more favorable presentation than that of the breech, and 
as such is subject to the same principles as if it were the primary 
position. After the first day the patient is up and around just 
the same as before, and will be confined at the usual term of 

pregnancy." 

These considerations 
serve to impress upon us 
the advisability of a careful 
external and internal exam- 
ination of every pregnant 
woman a week or two before 
the advent of labor. 

Cephalic Version During 
Labor. — When once partu- 
rient efforts have set in, 
cephalic version cannot so 
easily be performed, and, 
save under extremely favor- 
able conditions, ought not 
to be attempted. 

Other Operative Meas- 

Fig. 211.— Position of Foetus when ures — Operative measures, 

version is complete. apart from those already 

mentioned, will be considered under the head of "Operative 

Midwifery," and nothing need here be said concerning them. 

Expulsion of the Trunk.— As expulsion of the trunk takes 
place it may be received into a dry towel, which has the double 
advantage of providing warmth for the child, and a better hold 
for the physician. As soon as the umbilicus is reached, the cord 
should be drawn gently down, and carefully felt from time to 
time. If pulsation in it continues good, delivery need not be 
accelerated, but if it should fail, extraction must be hastened as 
rapidly as possible. 

Extraction of the Head.— The manner of effecting this has 
been before suggested. The child, wrapped in a towel, should 
rest on the most convenient arm, and the fingers on the canine 




Mechanism of Labor. 441 

fossae, enforcing flexion. Unless delivery is easily effected,, an 
assistant may make firm compression on the fundus uteri, while 
the woman is urged to make her best endeavor. The body must 
be carried well forward, if the case is occipitoanterior, and 
well backward if occipito-posterior, with gentle traction. 
Flexion of the head at the outlet, in occipitoanterior positions, 
is sometimes better effected through the rectum. Expulsion of 
the head may also be facilitated by the fingers in the rectum. 



442 Labor. 



CHAPTER IX. 

THE MECHANISM OF LABOR— Continued. 

Transverse Presentation.— When the foetal ovoid presents 
by neither extremity, but lies across the pelvis, we have what is 
known as ''transverse presentation." 

A number of varieties may be mentioned, such as ventral 
and dorsal, as well as shoulder and arm presentations. The 
fact is, that in the early stage of labor, almost any part of the 
trunk may constitute the presenting part ; but clinical obser- 
vation has taught, that, no matter what portion of the trunk 
may lie over the os uteri at the beginning of labor, as the case 
advances the shoulder or arm is quite sure to descend and 
constitute the presenting part. Hence in our succeeding re- 
marks on the mechanism of labor in these trying cases, the 
term "transverse presentation" will be understood as generic, 
and the principles of management suggested as applicable to 
every variety of it. 

FrequeiNCY— According to Dr. Geo. B. Peck's statistics, 
transverse presentation occurs once in 115 cases, which agrees 
with Depaul's observations. According to Dr. Churchill, the 
arm or shoulder presents once in 231% cases, but according to 
Dr. Peck, once in 180. It is much more frequently observed in 
multipara? than in pri mi parse. 

The Various Positions. — The positions of the foetus in 
shoulder presentation have been described in another place, and 
they do not need td be reviewed here. For the purpose of 
treatment, it is highly important that we distinguish them, as 
otherwise \\e cannot apply our treatment with intelligence and 
precision. 

Causes.— The causes of transverse presentation are not alto- 
gether clear. Any circumstance which may occur at the brim 
to divert the head from its usual place, and turn it into one of 
the iliac fossae, constitutes an efficient cause; and this may con- 
sist of a pelvic deformity; an unusual quantity of liquor amnii, 
giving to the uterus a form more nearly spherical ; obliquity 
of the long uterine axis ; or premature expulsive efforts. The 
great preponderance of transverse presentations among pluri- 
parae, would certainly give color to the theory of Wigand, 
that the phenomenon is dependent on the form of the uterine 






Mechanism of Labor. . 443 

cavity, which is probably widened in its transverse diameter 
and diminished in its longitudinal measurement. 

With regard to the time when the presentation becomes es- 
tablished, there is no uniformity. The change is sometimes 
wrought by a sudden movement, during, or at the beginning of 
expulsive efforts; while in other instances its existence is known 
to precede labor by days or weeks. 

Diagnosis.— The diagnosis of transverse presentation has 
been considered, in a general way, in another place; but a few 
observations may here be added. Abdominal palpation can 
scarcely fail to reveal the transverse direction of the long axis 
of the foetal ovoid. The enlargement is relatively broad, while 
the fundus uteri is really below the height at which it is usually 
found in cephalic and pelvic presentations. Deep palpation also 
reveals the head in one of the iliac fossae. On vaginal examina- 
tion the presenting part is found to lie so high that it cannot 
well be felt through the lower uterine segment ; and at the be- 
ginning of labor can scarcely be reached through the os uteri. 

The stethoscope affords some aid. " If the vaginal examina- 
tion has resulted fn the recognition of a portion of the foetus 
which is of small bulk," says Cazeaux, "and if we perceive the 
pulsation of the heart in the hypogastric region, we may almost 
certainly conclude that it is the superior extremity. If we 
heard the heart at the level of the umbilicus, it would in all 
probability be a leg." If the position is a dorso-posterior one, 
we will probably be unable to hear these sounds. 

Charpen tier's remarks under this head are so excellent that 
we here quote them. 

" The finger comes upon a rounded part with a prominent 
osseous point, the acromion ; on following this part we recog- 
nize successively the scapula, its spine, and the clavicle. But to 
recognize these different osseous prominences requires great 
experience in the touch, and for our part there is a landmark 
which outweighs all the others, the axillary cavity formed by 
the arm on one side and the thoracic wall on the other. More- 
over, this thoracic wall presents a series of eminences and 
depressions arranged parallel to each other like the bars of a 
gate, which Pajot terms the intercostal gridiron. The ribs 
being thus recognized, we are sure of having the lateral plane 
of the foetus before us. Again, the axillary cavity bounded by 
the arm and the thoracic wall represents an angle, the point of 
which is necessarily directed towards the head. It is, therefore, 



444 Labor. 

a certain means of indicating the side occupied by the head in 
cases where it has not been discovered by palpation. The 
axilla is sometimes difficult to reach in dorso-anterior cases, 
when the finger must be carried far back, and we can thus 
always recognize the ribs. In such a case we sometimes 
encounter the vertebral column of the foetus, which is marked 
by the row of projections formed by the spinous processes; on 
following them, we reach the scapula. 

"The head being recognized, and the anterior or posterior 
location of the back determined by the facility with which the 
ribs may be reached, the diagnosis is complete; that is to say, 
we know both the presentation and the position. 

"If we find — 

The head to the left, back anterior : it is the right shoulder. 
" " posterior : " " left 
" " " right " anterior: " " " " 

" " " " " posterior: " " right " 

" If we know the presenting shoulder and the position of the 
head, the diagnosis is likewise complete. 
"If we find- 
Right shoulder, back anterior, the head must be on the left. 

"' " " posterior, " " " " right. 

Left " " anterior, " " " " " " 

" " " posterior, " " " '' " left. 

"If, on the other hand, we know the shoulder and the situa- 
tion of the head, the diagnosis is likewise complete. 
"If we find — 

Right shoulder, head to the left, the back must be anterior. 

" " " " right, " " " posterior. 

Left " " " left, " " " posterior. 

" " " " right, " " " anterior. 

"Hence it is sufficient for us to know two terms of the 
problem to enable us to find the third. If instead of the 
acromial variety we have to deal with the cubital variety— in 
other words, if the elbow is the most accessible part — its recog- 
nition is sufficient to establish the diagnosis. The elbow is 
characterized by the projecting olecranon, limited on its right 
and left sides by two other prominences, the epi-condyle and 
the epi-trochlea. The bend of the elbow is formed by the fore- 
arm and the arm, and it is only necessary to follow either one 
of these parts to convince us that it is the elbow we are touch- 
ing. The forearm will lead to the hand, recognizable by being 






Mechanism of Labor. 



445 



in the axis of the arm, by the length of the fingers, the apposi- 
tion of the thumb, and the inequality of the fingers. In order 
to distinguish which hand we are touching, it is best to deter- 
mine the characteristics and the situation, and to substitute 
mentally our own for it. The one we can, as it were, superimpose 
upon the one felt will indicate whether it is the right or the left 
hand. This gives us the shoulder, or the elbow indicates the 
situation of the axilla ; in either case the diagnosis is complete. 
Pajot advises, in doubtful cases, to make traction on the hand 
felt externally and compare it with one's own ; this will show 
whether it is right or left. 

"If the hand is outside the vulva, it is sufficient to compare 
it with either one of ours to show whether it is the right or the 




Fig. 212. — Dorso-anterior posi- 
tion of the Foetus in Transverse 
presentation. 



Fig. 213. — Dorso-posterior posi- 
tion of the Foetus in Transverse 
presentation. 



left; but thereisamore scientific and equally reliable procedure. 
Take the protruding hand and turn it palm upwards, the 
border inferior to the symphysis pubis ; the thumb will always 
be turned to the thigh homonymous to the hand, to the right 
thigh in the case of the right hand, and vice versa. When the 
shoulder is known, we need but follow the arm to reach the 
axilla, and thus the situation of the head and the diagnosis is 
complete. 

" When the hand depends freely from the vulva, the arm in 
its natural attitude, simple inspection of the hand will complete 
the diagnosis. 

"The hand gives us the shoulder; besides, the back of the 
hand always turns away from the side where the head is. This 



446 Labor. 

gives us two terms of the problem, and we can find the third 
without difficulty and complete the diagnosis. But examina- 
tion of the hand suffices. 

"The hand gives us the shoulder; the dorsum of the hand, 
the situation of the head ; the direction of the thumb indicates 
the direction of the back ; for when the back is posterior, the 
thumb points upwards from the symphysis. When the back 
is anterior, the thumb is directed downwards towards the 
anus." 

Prognosis.— In any case, the danger to both mother and 
child is considerably augmented, yet the prognosis will be 
greatly modified by the stage of labor at which the case comes 
under observation. From carefully collected statistics, tabu- 
lated by Churchill, it appears that "out of 314 cases of presen- 
tation of the superior extremities, 175 children were lost, or 
rather more than one-half. Out of 282 cases, 30 mothers were 
lost, or nearly 1 in 9." Statistics of more recent practice 
would show a great reduction in the rate of mortality. 

Unaided Termination. — Dr. Rigby gave a. graphic picture of 
a case of transverse presentation when left to its natural ter- 
mination. "After the membranes have burst," says he, "and 
discharged more liquor amnii than in general when the head or 
nates present, the uterus contracts tighter around the child, 
and the shoulder is gradually pressed deeper into the pelvis, 
while the pains increase considerably in violence from the child 
being unable, from its faulty position, to yield to the expulsive 
efforts of nature. Drained of its liquor amnii, the uterus re- 
mains in its state of contraction even during the intervals of 
the pains; the consequence of this general and continued pres- 
sure is, that the child is destroyed from the circulation in the 
placenta being interrupted, the mother becomes exhausted, and 
inflammation and rupture of the uterus and vagina are the 
almost unavoidable results." 

In these days of enlightened midwifery practice such ca.ses 
are rarely committed to the natural efforts, thus hopelessly 
handicapped ; hence, w 7 hat we know of them is learned chiefly 
from old reports. 

Spontaneous Evolution and Spontaneous Expulsion. — Trans- 
verse presentations differ from the other presentations in 
having no regular and uniform mechanism of labor; but there 
are two movements occasionally observed, by the adoption of 
wdiich nature has succeeded in concluding the process of parturi- 



Mechanism of Labor. 



447 



tion ; these are spontaneous version or evolution, and what was 
designated by Douglas as spontaneous expulsion. 

Both have always been extremely rare. 

Spontaneous evolution or version consists in a complete 
version of the foetus begun by the escape of the shoulders from 
the grasp of the pelvic brim, followed by descent of the trunk 
and pelvis of the child. This process is not nearly so frequently 
observed as that of spontaneous expulsion, first described by 
Dr. Douglas, of Dublin. In this the shoulder does not recede 
from the brim and give place to the other parts, but it descends 
until it lodges under 
the pubic arch, where 
it constitutes a pivotal 
point about which the 
body of the child ro- 
tates. This constitutes 
version within the pel- 
vic cavity. " It will be 
obvious," says Leish- 
man, "that such a 
mechanism as this can 
only be possible under 
the same exceptional 
conditions which per- 
mit of spontaneous 
evolution. For in this 
case the breech must 
pass the pelvic brim, 
which is already partly 
occupied with the base 
of the skull, an occur- 
rence which is mani- 
festly impossible, if the 
relative proportion of the parts, maternal and foetal, are in 
accordance with the normal standard." 

The various stages of this important movement are made 
more lucid and impressive by the accompanying cuts than 
could be done by any number of words. 

Treatment.— No one point is of such importance as a 
recognition of the character of the case at the earliest possible 
moment. This involves, too, not a mere diagnosis of trans- 
verse presentation, but a recognition as well, of the position 




Fig. 214. — Showing a case of Transverse 
presentation wherein the liquor amnii has 
escaped, the arm has descended, and the 
shoulder is wedged into the brim. 



448 



Labor. 



occupied by the foetus, for upon this the success of treatment 
will largely depend. When such knowledge is obtained at the 
beginning of labor, or soon thereafter, we may look upon the 
case with composure, knowing that the issue lies in great 
measure under our control. Both mother and child are still 
possessed of unimpaired vitality, and the aim of our treatment 
will be to interfere before vitality has been seriously reduced. 
In fact we ought to have such close supervision of pregnant 
women who propose to give us the management of their labors, 
that the nature of the presentation shall in every instance be 
recognized before the day of delivery. 




Fig. 215. — Spontaneous Expulsion. (First stage.) 

The Favorable Moment for Operating.— The most opportune 
time is before the advent of labor, when, by external manipu- 
lation, cephalic version can usually be performed after labor 
begins; there likewise comes to all these cases a favorable mo- 
ment, and happy the accoucheur who discerns it with precision 
and is prepared to apply the suitable treatment with a vigor- 
ous hand, a wise judgment, and a courageous heart. 

Preservation of the Membranes.— It is of the utmost im- 
portance that the membranes be preserved intact up to the 
moment of interference. This consideration will lead to delicate, 
but none the less painstaking, digital exploration, which should 
be pressed only in the intervals between uterine contractions. 



Mechanism of Labor. 



449 



Version. — Some form of version is required in such presenta- 
tions, save in rare and neglected cases, wherein the expulsive 
process has gone so far as to destroy all reasonable prospect of 
success. 

The various methods of practicing version will be discussed 
in another chapter, and we are called upon in this place only to 
indicate the relative value of the different modes of performing 
it. Cephalic version, or a bringing down of the head, is suita- 
ble to most of those cases in which there is early recognition of 
the unfavorable nature of the presentation, and, under favora- 




Fig. 216. — Spontaneous Expulsion. (Second stage.) 

ble conditions, will scarcely fail of success. This is best prac- 
ticed by Dr. Braxton Hicks' method of conjoint manipulation. 
A mode of delivery in transverse presentation has been 
practiced with success by sojne, which is merely a modifica- 
tion of the Hicks method, consisting of the knee-elbow position, 
cephalic version by conjoint manipulation, and application of 
the forceps. Cephalic version is greatly facilitated, in some 
respects, by the knee-elbow position, since the force of gravity 
diminishes the pressure at the brim and places the child in a 
more mobile situation. When once cephalic version has been 
effected, the forceps are applied with the woman still on her 
knees and elbows, though the awkward posture does not permit 
it to be done with the usual facility. She is then permitted to 

(29) 



450 Labor. 

turn upon the back, and delivery is wholly or partially effected. 
What was a formidable case is, from the time of forceps appli- 
cation forwards, an ordinary instrumental delivery from above 
the pelvic brim, through a partly dilated os uteri. 

The form of version most commonly practiced is the internal 
podalic, which consists in introducing the hand within the 
uterus and bringing down the feet, the conditions favorable 
to which are an intact state of the membranes, and dilata- 
bility, or dilatation of the os uteri. 

When either of the first two modes of version is to be 
employed, only moderate dilatation of the os is requisite; but, 
when the last mode is to be adopted, labor should be atten- 
tively watched during the first stage, and if the membranes are 
preserved, and no serious S3 T mptoms are developed, we may 
safely await with patience the moment when dilatation will be 
nearly complete. Should the waters sooner escape, or should the 
presentation be descending too rapidly into the embrace of the 
pelvis, then, provided the os uteri is as large as a half-dollar, 
and in a dilatable state, the operation should be undertaken 
without unnecessary delay. 

The feet can sometimes be brought to the os uteri by the 
method of conjoint manipulation mentioned in connection with 
cephalic version. It is clearly the preferable mode if the case 
be a suitable one for its practice, inasmuch as an operation, 
in the performance of which only one or more fingers, instead 
•of the whole hand, are introduced within the uterus, must 
involve less risk than that attending the older method of 
drawing down the feet. Hence, unless the conditions surrounding 
the case offer positive discouragement to the conjoint method, 
it is advisable at first to make an attempt at version in that 
manner, and if it fail, then to have recourse to the more 
common method of internal version. 

In any case wherein we have, decided upon use of conjoint 
manipulation for the purpose of rectifying a transverse presen- 
tation, it ought to be undertaken as soon as the os uteri will 
admit two fingers, as delay beyond that time progressively 
diminishes the probability of success. 

But there is a class of cases quite different from these with 
regard to which apprehension will arise, and in the treatment 
of which great difficulty will be experienced. " Though always 
more or less dangerous," says Blundell, in his earnest, eloquent 
way, "the operation of turning may often be accomplished 



Mechanism of Labor. 451 

easily enough, provided it be performed early enough, and circum- 
stances conduce. Hence you will sometimes hear your obstetric 
acquaintances triumphantly exclaiming — ' For my part, I 
always turn without any difficulty;' a declaration, by the way, 
which evinces not their superior skill, but their small experience 
in the nicer and more dangerous parts of practice. In consul- 
tation, especially, we sometimes meet with cases of turning — 
embarrassed at once with difficulties and dangers : the body of" 
the uterus is constricted about the foetus ; the mouth and cervix; 
are more or less firmly contracted around the presenting part ; 
the passages are swelled, inflamed, and dreadfully irritable ; the 
patient, wearied with exertion, and desperate through suffering,, 
cannot be persuaded to lie at rest upon the bed; and tbus r 
sometimes, though rarely, a case is treated which might try the 
nerves and the muscles of even those minions of obstetric 
fortune, to whose superlative skill all difficulties give way." 

If the arm and hand have prolapsed, no attempt should be 
made to replace them before proceeding to operate. The woman, 
should be carefully brought under the influence of an anesthetic, 
not only to prevent suffering, but to allay uterine irritability^ 
which would interfere with a speedy and relatively easy accom- 
plishment of our purposes. The details of the operation will 
be given in another place. The necessity for the utmost gen- 
tleness and caution should be kept constantly in mind, for 
" wombs and women are not to be taken by assault." 

A thrust of the hand here is as fatal as a thrust of the 
bayonet. 

When the Foetus is Bead. — If the physician, on being called 
to a case of shoulder presentation, find clear evidence of foetal, 
death, he will be led to adopt a different method of treatment,, 
and one less hazardous to the woman. The signs in question 
are a flaccid, pulseless cord, if it can be felt, and exfoliation of 
the skin as the result of incipient maceration. For such cases 
evisceration is the treatment. 

Unaided Termination.— -In rare cases it may be obvious that 
labor is about to terminate without manual aid, by means of 
one of the movements previously described. During a pain, 
the child is observed to move in such a way as clearly to reveal 
its design to effect either spontaneous evolution or expulsion. 
Under such circumstances, the expectant plan of treatment is 
the proper one. " If the arm of the foetus," says Douglas, 
"should be almost entirely protruded, with the shoulder press- 



i 



452 Labor. 

ing on the perineum ; if a considerable portion of its thorax be 
in the hollow of the sacrum, with the axilla low in the pelvis; if, 
with this disposition, the uterine efforts be still powerful, and if 
the thorax be forced sensibly lower during the pressure of each 
successive pain, the evolution may, with great confidence, be 
expected." 

Other Operative Procedures. — When all other means have 
failed to effect delivery, and, again, when the foetus is certainly 
dead, it may be decapitated, it may be eviscerated, or it may 
be delivered through abdominal incision. 

Complex Presentations. — The most common forms of 
presentation, and even some of the uncommon varieties, have 
been mentioned ; but there are others of rare, though possible 
occurrence, wherein the presentation is compound in character, 
as, for example, when the hands and feet descend together. 
Most complex presentations are modifications of transverse 

positions, while in 
some, the long foetal 
and long uterine 
axes maintain their 
parallelism. A de- 
scription of one or 
two of them will be 
briefly given. 

Hand with the Head.— This is not an uncommon occur- 
rence, especially when the foetus is small in comparison with the 
pelvic canal. Labor does not become seriously impeded pro- 
vided extensive descent of the hand be prevented. But even 
when the arm becomes thrown down beside the head, the situ- 
ation does not constitute an effectual bar to labor, which, 
indeed, may still be terminated in a satisfactory manner. 
When from lack of room the complication becomes serious, 
suitable treatment consists in pushing up the arm by means of 
the half-hand in the vagina. In affording such relief it behooves 
us to be careful to avoid displacing the arm backwards, and 
thereby producing a, still more awkward condition of things. 

The Feet and Hands.— Both feet and both hands may pre- 
sent, or but one of each, and thereby form a variety of trans- 
verse presentation. Such a complication is sometimes still 
further increased by prolapse of the umbilical cord. Left to the 
natural efforts, the foot, or feet, after a time, are likely to re- 
cede, and a shoulder may descend ; or the presentation may not 




Fig. 217.— The use of the Fillet with a 
Kunning Noose. 



Mechanism of Labor. 453 

change, but be driven downwards, and finally become wedged 
into the brim. To prevent such an occurrence, the foot, or feet, 
should be seized, and drawn clown, while the hand is pushed 
upwards, thereby completing the operation of version at the 
expense of but slight effort. If this is undertaken early in labor, 
no great difficulty will be experienced ; but when attempted at 
a late period it may utterly fail, or at best be accomplished as 
the reward of strenuous and dangerous effort. In difficult 
cases a fillet ought to be attached above the ankle by a running- 
noose, and steady traction made upon it, while at the same 
time the hand is pushed upwards, and the version further aided 
by abdominal manipulation. When such a presentation is 
rendered still more complicated by descent of the funis, an 
attempt should be made to send the cord back into the uterine 
cavity with the presenting, but now receding, hand and arm, 
failing in which, the case should be treated as one of prolapsed 
funis with footling presentation. 

Both reposition of the cord, and completion of version, will 
be favored by putting the woman into the knee-elbow position. 

Head, Hand and Foot. — The head, hand and foot have been 
found presenting together, and to these has even been added 
prolapse of the cord. 

Version is here again a necessity, and should be undertaken 
at the earliest practicable moment. 

Other forms of complex presentation might be mentioned, 
but to do so would be useless, since their treatment is in ac- 
cordance with the principles already laid down. 

Prognosis of Complex Presentations. — Any form of presen- 
tation which involves the performance of so serious an opera- 
tion as podalic version, is always attended with increased risk 
both to mother and child. The degree of fatality obviously 
depends in great measure upon the stage of advancement in 
parturition at which interference is practiced, and the conse- 
quent difficulties which are encountered. 



454 Labor. 



CHAPTER X. 

PARTURIENT ANOMALIES REFERABLE TO THE EXPELLENT 

FORCES. 

Labor is said to be physiological in those cases wherein the 
natural forces are able to overcome the resistance usually of- 
fered by the soft parts, or the bony pelvis, without seriously 
injuring any maternal structure, consuming too much time, or 
considerably increasing the risk. It becomes pathological from 
entrance of a variety of disturbing elements referable to the ex- 
pellent forces, the maternal soft structures, the maternal bony 
structures, the foetus itself, and also various anomalous condi- 
tions. 

Patients judge labor pains by their subjective effects, and 
they therefore describe "cutting pains," "grinding pains," 
'"forcing pains/' and so on. The accoucheur judges of them by 
their objective effects, and therefore describes "efficient pains," 
''•propulsive pains," "unavailing pains," and so on. 

As the result of anomalous action of the expellenfc forces we 
accordingly have (1) precipitate labor and (2) protracted labor. 

In no two instances do we observe the same phenomena. 
Sudden and decisive changes occur at various stages of what 
may rightly be regarded as normal cases. That is to say, up 
to a certain point labor may progress with the utmost regular- 
ity and uniformity, the pains coming and going with clock-like 
precision, and dilatation proceeding without hesitancy. Descent 
may begin, and proceed well for a time, and then there comes a 
halt which causes the patient to lose heart. Again, a case may 
proceed in a leisurely manner up to a similar period in the pro- 
cess, when suddenly theexpellent forces take on new energy and 
bring the labor to an abrupt termination. 

Precipitate Labor. — There are several degrees of precipitate 
labor. In its milder forms it is commonly attended with but 
slight inconvenience, and as little danger. Such are the major- 
ity of easy labors. But there are cases in which the contrac- 
tions are so powerful, vehemeut, frequent and uncontrollable, 
as to result in serious traumatism of the cervix uteri, perineum, 
and even the body of the womb itself. The fetus traverses the 
parturient canal with such rapidity as to fall on the street, on 
the floor, into the chamber- vessel, or into the closet-bowl. In 



Pakturient Anomalies. 455 

cases like these the woman suffers few pains, but they are so re- 
doubled in severity as sometimes to produce convulsions, apo- 
plexy, and mania. When labor terminates with the woman in 
the erect posture the child's fall is usually broken by the cord, 
severance of which is rarely followed by hemorrhage. The in- 
voluntary efforts of the woman may be so strong, especially 
when the vulvar structures are still unrelaxed, and the pelvic 
floor offers stroug resistance, as to cause subcutaneous emphy- 
sema of the head and neck, to modify the utero-placental cir- 
culation, and even to fracture the foetal skull, as well as to 
result in laceration of the tissues in and about the vulva. 

The following remedies may be given, but w T e do not always 
have time to get their action before labor is brought to a close. 

Excessively severe labor pains: coff'ea, nux vomica, caulo- 
phylhim. 

Labor-pains too prolonged and powerful : secale. 

Chloroform serves to apply the brake more effectually and 
rapidly than anything else, and, if needful, it should be carried 
to the extent of deep anesthesia. 

Uterine Inertia.— Weak Labor.— In some women there is a 
lack of tone in nerve and muscular fiber which exercises a 
marked influence on the character of labor. k 'In women, more- 
over, of this temperament," says Leishman, "the anatomical 
peculiarities of the sex are generally well marked, and the ample 
and shallow pelvis thus offers a comparatively trifling resist- 
ance to the passage of the child. If, however, we contrast 
with this the tall, vigorous and muscular women, we find that 
in the latter there is a very general tendency to the male type 
of pelvis, involving a tardy passage of the child through the 
pelvic canal. May we not infer that it is in some degree in com- 
pensation for this that she is furnished with muscles so power- 
ful, and constitutional vigor so marked, to enable her to over- 
come the greater resistance which in a feebler frame would 
constitute an insurmountable barrier." 

We might with propriety include under the head of tedious, 
or prolonged labor, all cases wherein expulsion of the foetus is 
unusually delayed, from whatever cause delay may arise; but 
in this place we shall speak only of labor protracted from causes 
referable to deficient action of the expellent forces. 

The average duration of labor is from eight to ten hours, 
the latter for primiparse, and the former for multipara?. Labor 
may be wea,k from the very beginning, or, as we have said. 



456 Labor. 

inertia may develop in a case which, up to near the close of the 
second stage, has been vigorous and active. 

Causes. — Uterine inertia finds in general debility, — the result, 
it may be, of disease, — and in constitutional feebleness, a predis- 
posing cause. The immediate cause is most frequently attri- 
butable to over-exertion during a protracted first and early 
second stage, uterine inertia being an expression of the complete 
exhaustion from which the woman suffers. Kapid child-bearing 
doubtless has a marked effect in the same direction. Excessive 
and premature uterine retraction is an efficient cause in quite a 
percentage of cases; and also adhesions of the membranes to 
the lower uterine segment. High temperature of the surround- 
ing atmosphere, such as we get in the middle of a hot summer, 
because of its depressing effects may be reckoned as a cause. 
Sudden and profound emotion, in women of a highly nervous 
organization, is capable of weakening the pains, and even of 
temporarily suppressing them ; but the action of such a cause 
is not often sustained for a lengthened period. Overdistension 
of the bladder or rectum, and a condition of inflammation in the 
abdominal viscera, may be reckoned among the causes of this 
condition. Hydramnios should also be mentioned, its effects, 
however, being limited to the first stage. The age of the 
patient has a marked influence. In young girls there appears to 
be a proneness to weak and irregular uterine action, and in 
those nearing the close of the child-bearing period, powerless 
labor is by no means an infrequent occurrence. 

Symptoms. — In the first stage, weak labor is indicated by 
pains which come and go with little less than usual regularity, 
but which, while they may produce marked sensory impressions, 
further but slightly the parturient process. They are short, 
teasing and discouraging in character. When given an abund- 
ance of time they succeed at last in opening up the os uteri, 
and launching the woman, weary, worn and disheartened, into 
a powerless second stage. 

Then the case drags. There is little propulsive energy in the 
contractions, and the woman cannot bring herself to the exer- 
cise of much voluntary effort. There may not be absolute ar- 
rest of the parturient process, but it proceeds so slowly that 
progress has to be measured by hours. Left to itself, the case 
may ultimately culminate in spontaneous delivery, but occa- 
sionally it is overtaken by profound inertia, and requires arti- 
ficial aid. 






Parturient Anomalies. 457 

After the child is born the same leisurely movement contin- 
ues, and but for assistance the placenta would likely tarry in 
utero for an indefinite period. When once entirely empty, the 
uterus contracts in a listless, hesitating way, and, should there 
be in the patient a predisposition to hemorrhage, a serious ex- 
ample of it is liable to develop, unless averted by wise prophy- 
lactic measures. 

Treatment. — The following suggestion with regard to 
preventive treatment of these cases should be remembered : 
"The moment we find the least evidence of flagging power," 
says Dr. Edis, "of any cessation of pains, any intermittence in 
the regular beat, or any acceleration of the patient's pulse, or 
any general evidence of the patient having had more than she 
can fairly compass, I think we are bound in duty to assist the 
patient, and not allow her to go on until she is in powerless 
labor." 

The character of curative treatment will be determined by 
the causes contributing to inertia, and the stage of labor in 
which it is manifested. The condition of the bladder and 
rectum should be investigated, the mental state and age of the 
woman considered, and the character of the presentation, and 
state of the uterus, as regards retraction, passed under review. 
When it evidently depends on excess of liquor ainnii, the mem- 
branes, in the absence of contra-indications, may be ruptured, 
and a part of the fluid permitted to escape. Adhesions of the 
membranes to the lower uterine segment can be broken up by 
sweeping the finger about within the os uteri. A warm vaginal 
injection will sometimes promote uterine contractions and 
favor physiological reduction of the cervix. Barnes' bags are 
of service for opening the os, but far better and more effective, 
we believe, is manual dilatation practiced with the utmost 
caution. 

In protracted second stage, resulting from inefficient 
uterine action, much aid can be afforded by properly directed 
manual pressure on the fundus uteri. It is better borne in 
labor which is prolonged through weakness of the expellent 
forces than in labor which is protracted by reason of re- 
sistance in front of the presenting part. In the latter case the 
energetic uterus resents interference, but in the former it 
invites it. 

Aid of this kind should be given by the palms of the hands, 
and pressure made in the direction of the long uterine axis. It 



458 Labor. 

need not be added that there is no intention to supplant the 
natural efforts, but to reinforce them. 

When the head, in cases of uterine atony, lies at the outlet, it 
can usually be expelled by means of two fingers in the rectum, 
combined with abdominal pressure. 

Ergot has been commonly employed by the old school for 
the purpose of arousing the sleepy uterus, but even among its 
own practitioners the drug is falling into disrepute. In our early 
practice we also cherished a liking for it, but are now convinced 
that the outcome is likely to be more gratifying when strict 
homeopathic indications are followed. 

The appended therapeutic hints are not intended to be specific 
guides in practice, but mere finger-boards pointing to the 
possibly indicated remedies. In order to obtain satisfactory 
results from our remedies they must be chosen with due regard 
to temperament, constitutional traits, known systemic taints, 
and the peculiar individual symptoms of each case. 

Therapeutics.— Inefficient. — Labor-pains violent and fre- 
quent, bat inefficient; patient says she cannot breathe; is 
restless, anxious and impatient ; aconite. 

Labor-pains too weak, but regular; sethusia. 

Labor-pains violent, but inefficient ; feels lame and bruised ; 
arnica. 

Labor-pains tormenting, but useless, in the beginning of 
labor; caulophyllum. This is an excellent and frequently 
indicated remedy, especially in rheumatic patients. 

Labor-pains short, irregular, spasmodic; patient very weak; 
no progress made: caulophyllum. 

Labor-pains spasmodic and irregular, especially in women 
who have had great grief or anger : cocculus. 

Labor-pains spasmodic: causticum, ferrum, Pulsatilla, mix 
vomica. 

Labor-pains spasmodic, cutting across from left to right, 
nausea, clutching about the navel : ipecac. 

Labor-pains spasmodic, painful but ineffectual : platina. 

Labor-pains spasmodic; they exhaust her greatly: stannum. 

Labor-pains spasmodic and distressing; patient irritable: 
chamomilla. 

Labor-pains weak and inefficient; patient weak; has slow, 
feeble pulse : caust., kali carb. 

Labor-pains distressing, but of little use; cutting pains 
across abdomen : phosphorus. 



Parturient Anomalies. 459 

Labor-pains ineffectual, of a tearing, distressing character, 
seemingly not properly located : aetata. 

Labor-pains prolonged, but ineffectual: secale. 

Labor-pains severe, but not efficacious; she weeps and 
laments : coffea. 

Weak, false, deficient. Labor- pains weak or ceasing; she 
wants to change position often ; feels bruised : arnica. 

Labor-pains weak or ceasing; she will not be covered; rest- 
less ; skin cold : camphora. 

Labor-pains deficient or absent; she has only slight peri- 
odical pressure on the sacrum; amniotic fluid gone; os uteri 
spasmodically closed : belladonna. 

Labor-pains weak or ceasing, with great debility, especially 
after violent disease or loss of animal fluids : carbo veg. 

Labor-pains become weak, flagging, from protracted labor, 
causing exhaustion ; patieut thirsty, feverish : caulophyllum. 

Labor-pains cease from loss of blood : china. 

Labor-pains ceasing, with complaining loquacity : coffea. 

Labor-pains gone, os widely dilated, complete atony: gel- 
semium. 

Labor-pains feeble and inefficient; patient anaemic, weak; 
slow, feeble pulse : causticum, kali carb. 

Labor-pains weak, accompanied with anguish and sweat; 
desires to be rubbed : natrum mur. 

Labor-pains spasmodic, irregular ; drowsiness: natrum mur. 

Labor-pains deficient, irregular, sluggish ; patient has light 
complexion, blue eyes, tearful mood : Pulsatilla. 

Labor-pains deficient, irregular, sluggish ; patient has dark 
hair and eyes : nux vomica. 

Labor-pains deficient, with os soft, pliable, dilatable: usti- 
lago. 

Labor-pains suppressed, or too weak : secale. 

Labor-pains cease; coma, retention of stool and urine, from 
fright: opium. 

Labor-pains cease, or become weak, from anger : chamomilla, 
colocynth, cocculus. 

Labor-pains cease from excessive grief : ignatia, cocculus. 

The Forceps in Inert Labor.— There is occasion for the 
utmost discretion in the use of the forceps in cases of weak 
labor proceeding from real uterine atony. We should here 
distinguish between the latter condition and that of premature 
or excessive uterine retraction. In the latter instance, the in- 



460 Labor. 

struments are not only called for, but there is little, if any, 
danger attending their use. The same cannot be said of the 
former condition. The head in a given case descends into the 
pelvic cavity under the influence of fair pains ; but after a time 
the pains become so feeble that progress is arrested. Long 
delay under such circumstances is not free from serious danger 
to the woman, owing to continuous compression of the soft 
pelvic tissues. Recourse is had, perhaps, to various well-indi- 
cated remedies, without relief. The uterine energies are either 
too broken promptly to respond, or, after a time, the forceps 
are applied and delivery finished without difficulty; but we find 
that the uterus, instead of assuming its usual cannon-ball con- 
traction, remains weak and sluggish, with the effect to develop 
an aggravated attack of post-partum hemorrhage. The dan- 
ger, then, in all such cases is, that the atony with which the 
uterus is stricken will continue, and excessive bleeding result. 
On the other hand there is little danger of such an occurrence 
in connection with la,bor rendered weak by the premature or 
excessive retraction of the uterus alluded to above. 

Now, if beforp using the forceps, even moderate re-awakening 
of the organs be secured by remedies and the application of 
suitable stimulus, we may proceed slowly with our forceps de- 
livery without incurring much danger of subsequent hemor- 
rhage. Unless a complete atony exists, the very introduction of 
the instrument communicates a certain degree of stimulation of 
the most effective kind, so that our traction efforts are often found 
to be reinforced by vigorous uterine action. The point which 
we wish to establish is that, bearing in mind the dangers which 
are most liable to arise, we should fortify ourselves against 
them by adopting such precautions as are described in connec- 
tion with the prophylactic treatment of post-partum hemor- 
rhage. 

Treatment of the Third Stage of Labor Complicated 
by Uterine Inertia. — The great danger associated with 
uterine weakness in the third stage of labor is that of post- 
partum hemorrhage. A sluggish uterus in this stage is always 
the cause of much anxiety. Hemorrhage may set in early, im- 
mediately succeeding placental delivery, or it may not appear 
at all. There should be no haste to deliver the placenta, and 
no traction on the cord. With the hand firmly grasping the 
organ through the abdominal walls, we should for a time main- 
tain an expectant attitude, unless bleeding set in. We must 



Parturient Anomalies. 461 

watch and wait. The recurrence of firm uterine contraction 
will be taken as a signal for delivery of the jjlacental mass by 
pressure on the fundus, combined with moderate traction on 
the cord 

Following such a delivery the uterus ought to be firmly held 
for twenty or thirty minutes. 

With a weak third stage of labor irregular uterine contrac- 
tion is often associated, the fibers of a certain part acting more 
energetically than others and forming a constriction, most 
frequently at one angle of the uterus, but often at or near the 
site of the internal os, by means of which the placenta is 
retained. The stricture does not often long persist, but it may 
be soon overcome by action of the suitable remedy. Belladonna, 
gelsemium, cuprum and caulophyllum are indicated in a general 
way, and our choice between them will be based on the special 
symptoms observed. 

Belladonna. — With this remedy the patient is disposed to be 
quiet; is usually plethoric, and in good flesh; withal, during 
the labor she may have complained of occipital headache. 

Gelsemium. — The woman desires to be left alone; is nervous 
and excited ; may be more or less hysterical. 

Cuprum. — Is especially suited to women who have a good 
deal of cramping of various muscles during pregnancy, and in 
whom the pains of labor take on a somewhat crampj^ nature, 
especially in the early stage. 

Caulophyllum. — Patient weak and nervous, and the uterus 
sensitive to pressure. 

Many other remedies may be found serviceable, among 
which are — 

Chamomilla. — The woman is irritable, thirsty and restless; 
desires fresh air; declares she cannot endure her distresses. 

Cocculus — This remedy is especially suited to women who 
have recently been greatly stirred by grief or anger. 

Aniyl nitrite by inhalation is very effective in some cases. 
Only a few drops should be inhaled, and even then with caution. 

Under no circumstances should a patient be left alone until 
the placenta has been delivered, for the muscular fibers of the 
body of the uterus may relax and give free vent to hemorrhage. 

Forcible reduction of an irregular contraction of the uterus 
should not be undertaken at once, unless alarming hemorrhage 
sets in. Patient waiting and careful prescribing usually bring 
about the desired result. Should there be failure, a gentle but 



462 Labor. 

firm endeavor to overcome the spasmodic condition ought 
after a time to be made, in order to release the placenta. The 
method of doing so is thus given by Lusk: "The plan I have 
followed of late years, with uniform success, consists in intro- 
ducing the index and middle fingers, with the whole hand in the 
vagina, to the point of constriction. Then, by pressing the 
uterus downwards, the fingers are brought in contact with the 
placental border. Now, it is only necessary to draw a single 
cotyledon into the canal to render the further extraction a 
matter of certainty. Under the pressure of the soft placental 
mass the stricture relaxes slowly. By combining expression 
with slight traction, the delivery is surely accomplished. The 
principal difficulty of the operation lies in the manipulations 
needful to bring the placenta at the outset to the point of 
stricture, but this difficulty can be pretty certainly overcome 
by patience and the determination to succeed. During the 
period of withdrawal the operator should be content with a 
very slow progression, proportioned to the yielding of the 
tissues ; otherwise the presenting portion of the placenta tears 
away, when the labor expended is lost." 



Parturient Anomalies. 463 



CHAPTER XI. 



PARTURIENT ANOMALIES REFERABLE TO THE MATERNAL 

SOFT PARTS. 

Much difficulty is experienced by the foetus in its escape from 
the uterus and passage through the pelvic canal, proceeding 
from faulty conditions of the maternal soft parts. Among 
fchese we may name, rigidity of the os uteri, atresia of the cer- 
vical canal, tetanoid constriction involving the lower uterine 
segment, tumefaction and incarceration of the anterior lip of 
the os, carcinoma of the cervix, thrombus of the vagina and 
vulva, cystocele, scybala in the rectum, calculi in the bladder, 
uterine polypi, ovarian growths and rigid perineum. 

Rigidity of the Cervix Uteri.— Rigidity of the cervix 
arises from different causes, and is dependent on various 
pathological conditions. 

1. It may come from incompletion of the physiological 
process of softening, which takes place during pregnancy, and 
is usually more or less pronounced in every case of premature 
labor. 

2 Abnormal rigidity of the os externum is often en- 
countered in multipara? as the result of genuine cicatricial pro- 
cesses. 

3. Fibrous hypertrophy of the cervical body is occasionally 
met. This condition is especially observed in connection with 
prolapse of the uterus. 

4. Carcinoma of the cervix, as mentioned in another place, 
gives rise to most persistent rigidity. 

5. In aged primiparse, atrophic degenerative changes in the 
cervical tissues, or hypertrophy of the portio-vaginalis, make 
the os reluctant to yield. 

6. A certain degree of rigidity of the cervix is observed in 
connection with general tonicity and firmness of tissue, espe- 
cially in young and robust primiparse. 

7. Last of all, we have a condition vastly more common 
than any of the others, and which is most frequently signified 
when the term " rigid os " is employed ; we mean a spastic state 
of the circular fibers of the cervix ; a trismus of the part ; spas- 
modic rigidity. The others are instances of mere passive 
rigidity, or non-dilatability. 



404 Labor. 

Generally speaking, spasmodic rigidity is an occurrence 
which exists quite independently of any diseased condition of 
the parts, and is, in fact, a purely functional lesion. It is found 
in various degrees of intensity, from that which causes but 
slight delay, up to the aggravated forms which hold out 
most stoutly against the measures adopted for their sub- 
jugation. 

Symptoms. — In the more obstinate cases of the spasmodic 
form, the os either refuses to dilate at all, or expansion advances 
to the size of a silver half-dollar or dollar, and remains un- 
changed for hours, or, in badly managed cases, even days, in a 
thin, hard and unyielding condition, notwithstanding the force 
exerted by the longitudinal and oblique fibers of the uterus to 
overcome it. It occurs most frequently in premature labor, 
when the cervix and lower segment of the uterus have not com- 
pleted their physiological changes. It is commonly associated 
also with malpresentations. In some instances the lips of the 
os become oedematous and hypertrophied, and to the finger 
seem thick and tough, while the undilatability remains. (Edema 
occurs most frequently in stout plethoric women, at a time 
when pressure by the head has been long continued, especially 
after escape of the liquor amnii. It should not be confounded 
with a condition, somewhat similar, often observed in multi- 
parse during the progress of dilatation. 

Spasmodic rigidity owes its origin to constitutional pecu- 
liarities, more especially a highly-nervous and emotional tem- 
perament, which can scarcely bear the ordinary pains of labor. 

The sufferings of a woman during the period in which her 
cervix uteri is in a state of rigidity, are often intensely agoniz- 
ing, just as in tonic spasm of muscles in other parts of the 
body. Madam Lachapelle considered severe pain in the loins as 
a valuable diagnostic sign of this condition. 

It would appear from reports, that, in the practice of some, 
labor is complicated by rigidity of the os uteri in quite a large 
percentage of cases. Young practitioners are especially liable 
to such experiences. But, right here they fall into error, and 
upon this wise : They make an examination per vaginam during 
a pain, and find the os uteri with hard and rigid lips. " Surely," 
they say, " this is a rigid os," and they so regard it. Had they 
tested the condition of the part during the interval between 
contractions it would have been found pliable, perhaps to a 
marked degree. 



Parturient Anomalies. 465 

After the pains have continued for a long time with but little, 
if any, progress of dilatation, they begin to lose vigor; the 
patient's tongue becomes spread with a dry, brownish coating, 
the skin hot, the pulse rapid, and the vagina and cervix hot 
and dry. Such symptoms are hastened by a dry birth, whether 
the waters have escaped through spontaneous, or through 
artificial, rupture of the membranes. 

Further consideration is devoted to most of the other forms 
of rigid os uteri a little further on. 

Treatment. — Immediate danger is not to be apprehended 
from a rigid state of the os uteri, and hence there is commonly 
no immediate urgency for more energetic measures than the 
administration of the indicated remedy. Later, if the condi- 
tion persist, the woman may take a hot sitz-bath, for a few 
moments only, or a prolonged hot-water vaginal douche. 

In the treatment of old-school physicians, opium is here re- 
garded as the most precious remedy, and belladonna stands 
second. 

Dilatation with Bags. — When the head remains high in the 
pelvis, and the membranes are unruptured, the finger cannot be 
used to advantage, or the mode of digital dilatation described 
below would be recommended. If our remedies have failed, it 
will then be necessary to resort to the caoutchouc dilators to 
accomplish the necessary expansion. Barnes bags are pro- 
vided in different sizes. The smaller ones should first be used, 
and substituted by those of larger size as rapidly as expansion 
of the os will permit. 

Manual Dilatation. — In these cases of spasmodic rigidity of 
the os uteri, digital dilatation may be safely and efficiently 
practiced. It should not be undertaken without resort having 
first been had to medicinal aid ; but that failing, as sometimes 
it will, a careful, skillful, persistent effort with the fingers will 
generally accomplish the desired end. Explicit directions for 
doing this are not required ; but we may say that, so long as 
dilatation of the os is but slight, we can best operate by draw- 
ing and pressing on the lips, in various directions, when room 
will soon be made for a second finger, and then, by spreading 
the digits, further dilatation can be secured. 

Incision of the Cervix. — Vaginal Hysterotomy. — If all other 

means fail, as they rarely will, the cervix uteri may be incised 

in its circumference, with a blunt-pointed bistoury, in three or 

four places, to the depth of a quarter of an inch. Afterwards 

(30) 



466 Labor. 

the natural efforts will be sufficient to carry on the dilatation, 
or it may be promoted by judicious use of the fingers. The 
conditions demanding such treatment are exceedingly rare, and 
it should not be applied without due deliberation. 

Use of the Forceps. — It is becoming the practice of the more 
advanced obstetricians to resort to the forceps in certain cases 
of rigid os uteri. Instead of following the old rule, to await 
full dilatation before using the instrument, a restriction which 
would exclude it in all instances of partially dilated os, they re- 
sort to the forceps, in obstinate cases, as soon as expansion is 
ample enough to admit the blades. The operation is especially 
called for when, as sometimes happens, a rigid os is associated 
with puerperal eclampsia. In some cases it is deemed wise to 
incise the os before applying the instrument. 

In all cases wherein the forceps are employed before complete 
dilatation of the os, the greatest care is necessary. The forci- 
ble words of Blundell are here appropriate. " The grand error 
you are apt to commit, in using the long forceps, is force. In 
violent hands, the long forceps is a tremendous instrument. 
Force kills the child ; force bruises the soft parts; force occasions 
mortifications ; force bursts open the neck of the bladder ; force 
crushes the nerves ; — beware of force, therefore; arte non vi!" 
A gentle, cautious, but resolute effort with the forceps, in cases 
of rigid os which have resisted other means, will generally be 
rewarded with success. 

Craniotomy. — If there is considerable pelvic contraction, or 
if, from other causes, the forceps are inadequate to effect 
delivery, the accoucheur may be driven to the necessity of em- 
ploying that terrible instrument the perforator. Dr. A. K. 
Gardner gives expression to the following sentiments respecting 
the last two operations: "If, therefore," says he, "there be 
any immediate necessity for any obstetric operation, do it 
irrespective of the local condition ; apply the forceps through 
an undilated os ; perform craniotomy through a but partially 
dilated os; and even, if necessary, incise the os, in order to 
render an operation practicable." The conservative obstetrician 
will be very reluctant to use the perforator in such a case, and 
we verily believe that when properly managed, spasmodic 
rigidity will never create a demand for the operation. 

Therapeutics. — Here is a functional disturbance constituting 
for the time an effectual bar to parturition, and to its correc- 
tion our remedies are peculiarly adapted. Votaries of the old 



Parturient Anomalies. 467 

school often fail to obtain the desired result with their heroic 
measures, but the homeopathic similimum, even in the highest 
potency, will unlock the spasm and again set the parturient 
energies into normal action. 

Aconite.— This is the remedy when there is diminished mois- 
ture in the vagina, and the woman becomes restless, excited 
and thirsty. 

Belladonna— No remedy is so frequently indicated in spas- 
modic rigidity of the os as this. It is peculiarly suited to 
primiparse, and especially those of the two extremes of age — 
the young and the old. Again, it is best adapted to women who 
are plethoric or are subject to vascular fullness of the head 
and face; the patient is irritable; labor-pains are unusually 
severe, but the patient bears them with considerable fortitude. 

Local application of the drug does not materially aid its 
medicinal action. 

Gelsemium. — For nervous, hysterical women; great agita- 
tion ; women under the power of depressing emotions. 

Caulophyllum.—We regard this as an excellent prophylactic 
of spasmodic action during labor, if the least tendency to it be 
observed. In our practice it is not employed in a routine way 
before labor, but is frequently administered at the beginning of 
the act. It is often indicated in women with rheumatic tenden- 
cies, and those with a history of sparing menstrual loss. 

Calcarea carb— Strange as it may appear to some, this 
remedy is of service in women presenting many of the indica- 
tions for belladonna. The temperament and general appear- 
ance are nearly the same, save that, whereas the belladonna 
patient sometimes has a pallid countenance, the calcarea 
patient nearly always has it. 

There are doubtless many other serviceable remedies, but 
the effective one is likely to be found among those which we 
have given. 

Uterine Tetanoid Constriction.— It may occasionally hap- 
pen, during labor, that progress is impeded by the occurrence of 
a circular tetanoid contraction of a limited portion of the 
muscular fibers of the uterus, above the internal os. 

Character of the Stricture.— Hosmer likens the stricture 
to a band of metal; Davis says the uterus is "as if a strong 
rope had been tightly drawn around it;" and Gay says, "It 
felt as hard as bone, and at first was mistaken for bone." Dr. 
Reamy says: "Nothing which I had ever encountered in uterine 



468 Labor. 

contraction could convey any idea of the power of the constric- 
tion." 

Diagnosis. — The stricture may sometimes be made out from 
careful abdominal palpation, but we are liable to confound the 
feel with that of premature and excessive retraction of the 
uterus, mentioned under the head of "Uterine Inertia." It will 
be distinguished from that condition mainly by the general 
characters of the labor, which do not point originally to weak- 
ness, but to obstruction. Then, too, vaginal examination does 
not reveal premature disappearance of the os uteri such as 
we get from retraction over the presenting part, though it 
must be remembered that this does not always accompany 
the anomaly mentioned. 

Treatment. — The operations usually performed to over- 
come obstructions have generally been resorted to, but with 
most unsatisfactory results. Cesarean section itself has been 
suggested. Such cases are rare, and we are not aware of the 
success which has attended the use of homeopathic remedies in 
their treatment, but we should expect good results from bella- 
donna, gelsemium, naulophyllum, and perhaps aconite. It may 
be that amyl nitrite will prove efficacious. Chloroform has 
failed to unlock the spasm. 

Atresia of the External Uterine Orifice.— There have 
been but a few cases of this form of obstruction reported. It is 
probably the result of inflammatory action, and has been 
known to occur after cauterization employed for endocer- 
vicitis. 

Though these adhesions resist firm uterine contractions, and 
constitute a bar to labor, they may be broken up by the finger, 
with loss of but a few drops of blood. 

Complete Obliteration of the Cervical Canal.— This is 
an extremely rare condition. It differs from simple agglutina- 
tion of the external os chiefly in the greater strength of the 
adhesion, operative measures being required to overcome it. 

Vaginal hysterotomy is the treatment required. If the site 
of the original opening can be found, an incision should be 
made with a bistoury, in a transverse direction, to the extent 
of half an inch. Or, the uterine tissues may be picked up with 
a pair of toothed forceps, and then divided with scissors. 

Tumefaction and Incarceration of the Anterior Lip- 
When descent of the head begins, as it frequently does, before 



Parturient Anomalies. 469 

retraction of tne cervical ring has taken place, the anterior lip 
of the os uteri may become compressed and held between the 
head and pubes. This condition usually disappears spontane- 
ously, without becoming excessive; but now and then it will 
require relief. 

Treatment consists in pressing upwards the tumefied part, 
in the interval between pains, and maintaining it in a situation 
above the brim, until the head descends far enough to prevent 
its return. Two or three attempts may be required to effect our 
purpose. Three precautions are to be observed, namely: (1) 
avoidance of much manipulative force, (2) dextrous use of the 
fingers so as not to cut the cervix, and (3) making sure that 
the case has proceeded so far that retraction of the anterior lip 
ought to occur. 

Blot mentions a case in which the tumor formed by the 
anterior lip, thus confined, was an inch and a quarter thick, and 
descended to the vulva. The labor had to be terminated with 
the forceps. 

Sanguineous tumors have resulted, which, upon rupturing 
either during or after labor, have created serious, and even 
alarming, hemorrhages. 

In our efforts to avoid such a complication we should beware 
of too much, and too early, manipulation of the part. 

Carcinoma of the Cervix. — The cervix uteri is the occasional 
seat of cancerous degeneration during the child-bearing period, 
and the result is extensive thickening and induration of the 
part. Carcinoma of the cervix, even in an advanced state, is 
not an absolute preventive of conception, but the latter rarely 
occurs, and even then manifests a strong tendency to terminate 
in foetal death and premature expulsion. The vascular fulness 
and elaboration of pregnancy cause rapid development and 
progress of the disease. 

Delivery is sometimes effectually obstructed, especially by 
the harder forms of the growth. When it does take place the 
cervical mass is fissured by the necessary expansion. 

If artificial intervention be demanded, it may be found neces- 
sary to make repeated incisions into the cancerous mass with a 
view to provide for cervical expansion. Subsequently the labor 
may be instrumen tally terminated, or left to the natural 
efforts. If, after making as free incisions as the degree of involve- 
ment will justify, the cervix is still too contracted to admit the 
forceps, — a thing which rarely occurs,— the choice of operative 



470 Labor. 

procedure will lie between craniotomy and Csesarean section. 
Cazeaux thinks that, so far as the maternal risks are concerned, 
they are about equal in craniotomy and Cesarean section ; and 
since the former involves certain death to the child, the latter 
is the preferable operation, in which conclusion we quite 
agree. 

Cauliflower Excrescence.— Growths of this character may 
arise from either lip of the cervix and finally come to involve 
the whole os. 

A singular error in diagnosis, in connection with such a 
morbid development, occurred some years ago in the Lucerne 
hospital. It is said that one of the internes, to whom fell the 
management of a case of labor presenting a cauliflower growth 
with a pedicle an inch and a half in length, sent for his chief, M. 
Nelaton, to perform version, under the impression that he had a 
case of arm presentation. 

When these tumors have been found so large as to prevent 
foetal expulsion, they have sometimes been removed ; while in 
others, craniotomy and laparotomy have been performed. 

Thrombus of the Vagina and Vulva.— Effusion of blood 
into the pelvic cellular tissue surrounding the vagina and vulva 
constitutes a serious complication of labor. The location and 
extent of the involved area is determined by the anatomical 
structure of the part into which the extravasation takes place. 
In bad cases the effusion is not limited to a small area, but it 
may extend for a considerable distance, and acquire considera- 
ble size. 

The accident is rare. Dubois had only three cases in 1,400 
deliveries; Winckel one in 1,600, and Charpentier only one in 
1,800. 

The accident is usually developed suddenly in the latter part 
of labor, but does not commonly show itself till after delivery. 
Occurrence of rupture is heralded by severe pain, but it is not 
easily differentiated from the ordinary pain of a strong labor. 
Distension sometimes becomes so excessive as to occasion 
rupture of the integumental coverings, followed by considera- 
ble hemorrhage. When the extravasation takes place before 
labor, the resulting tumor may constitute a serious impedi- 
ment to passage of the fetus. 

If the effusion is not excessive, it will likely be absorbed ; but, 
when a large thrombus forms, rupture, suppuration or gan- 
grene is quite sure to result. 



Parturient Anomalies. 



471 



Treatment.— When the thrombus is large, and lies in ad- 
vance of the descending head, it will act as a formidable obstacle 
to spontaneous delivery, and, until reduced, may even forbid 
extraction with the forceps. In the latter case, free incision is 
the treatment, followed by immediate delivery. The cavity 
may then be temporarily packed with iodoform gauze, after 
thorough cleansing. When thus the hemorrhage has been 
checked, the wound should be closed with a continuous catgut 
suture, a single row of stitches being carried first through the 




Fig. 218. — Cut showing Cystocele. A represents the prolapsed bladder. 

depth of the wound in order to insure perfect apposition of the 
cavity walls. 

In the cases which first present after delivery, the expectant 
plan of treatment should be adopted, unless the tumor is very 
large, or presents evidences of suppuration. 

When the effusion is left to absorptive action, final recovery 
is more tardy than when it is removed through free incision. 
Over against this is Hervieux's statement that death has oc- 
curred more frequently under the latter treatment, but usually 
from hemorrhage which surgical skill should now be able to 
control.- 

Cystocele.— This is a frequent complication of labor, but 



472 Labor. 

ought rarely to become a serious oue. In neglected cases the 
bladder, by descent of the head, becomes divided into two com- 
partments, and the lower one is pushed down in advance of the 
head. Still, it is evident that this can occur only as the result 
of inattention to proper evacuation of the viscus. If the part 
thus compressed is considerably distended, and does not receive 
suitable attention, it may offer decided resistance to advance 
of the head, and finally be overcome through serious injury. 

Some authorities hold that the accoucheur is not always 
responsible for the development of this complication of labor, 
even though present from the beginning of the parturient effort, 
since the cystocele may antedate labor by weeks, months, or 
even years. Nevertheless we can but feel that, though an old 
cystocele may descend in advance of the presenting part and 
constitute an annoyance, it can be prevented from offering 
serious resistance, or falling into great danger of suffering 
severe injury. 

Treatment consists in passing a soft rubber catheter and 
drawing off the confined urine. This should be done in the 
interval between pains, when the head is not pressing so heavily 
against the pubes, and, if necessary in order to secure room, 
the head can be repressed by the fingers. If the catheter can- 
not be introduced, the bladder may be punctured per vaginam 
with a hypodermic needle, or the small needle of the aspirator, 
and relief thus afforded. In any event there is no good excuse 
for allowing the organ to rupture under these circumstances. 
Even after emptying this compartment of the bladder, it may 
be necessary deftly to repress it from time to time. 

Rectocele. — The posterior vaginal wall, including the recto- 
vaginal septum, may prolapse during labor, but it can scarcely 
constitute a formidable impediment, unless hardened foecal 
accumulations are contained in the rectal pouch thus formed. 
Eemoval of such offending matters is usually accomplished 
with facility. 

Vesical Calculus. — This complication of parturition has 
been met in a large number of recorded cases. When the stone 
is large, and it descends before the foetal head, labor cannot be 
finished without its spontaneous, or operative, removal. In any 
neglected case, laceration of the bladder, and vesico-vaginal 
fistula are the almost certain results. 

Diagnosis is readily made, for the stone, from its situation 



Parturient Anomalies. 473 

and movable character, cannot easity be mistaken for any 
other complication of labor. These cases demonstrate the 
importance of timely vaginal examination, for when the stone 
is early detected, it can generally be pressed above the pubes, 
in which situation it is not so apt to produce mischievous 
effects. If the labor has advanced too far to admit of such 
treatment, or if the size of the stone is too great, the rule is to 
perform the operation of lithotomy through the vagina. If 
time and opportunity are auspicious, lithotrity is in some cases 
the preferable procedure. 

Diffuse Swelling.— Swelling and tumefaction of the soft 
parts of the parturient canal are liable to complicate expulsion. 
In various forms of obstructed labor, as, for example, in de- 
formed pelvis, the long continued pressure, and the repeated 
uterine contractions and muscular effort, give rise to the com- 
plication. A similar condition is sometimes noticed in connec- 
tion with ordinary labor, due, probably, to intense Iryperseniia 
and irritation. If excessive, hot water injections will bring 
about some reduction, but if the bladder and rectum are kept 
clear, little harm is likely to ensue. 

Unyielding Hymen.— As mentioned in another place, 
women occasionally become pregnant through a cribriform 
hymen, and in other cases through one possessing but a single 
small aperture, and the structure, owing to its unusual tough- 
ness, remaining unbroken, forms an obstacle to delivery. Left 
to the natural course of events, these membranes, however 
hard, would probably be ruptured by the descending foetus; 
but more or less delay and unnecessary pain would be suffered. 
It is far better to dispose of them by making a crucial incision, 
before pressure or strain has become excessive. It is probably 
better still, when such conditions are recognized during preg- 
nancy, to make the necessary incisions at once, as there is no 
danger, and but little pain, attending the operation. 

Uterine Polypi.— Polypoid growths springing from the 
uterus at the os, the interior of the cervix, or the cavity of the 
uterus, when they exist in the non-pregnant, commonly prevent 
conception; but there are exceptions to the rule. In other 
cases they are developed, or greatly augmented, during gesta- 
tion, and, at the beginning of labor, emerge from the os uteri 
and act as impediments to the natural processes. When they 
arise from the lips of the os, they are usually of small propor- 



474 



Labor. 



tions, and of cystic character, offering no obstruction to labor. 
Those which spring from the interior of the cervix, or of the 
corpus uteri, are larger, and of a fibrous nature. Unless they 
are so large and unyielding as to constitute a positive bar 
to delivery, they should not be removed. The uterine con- 
tractions are sometimes forcible enough to detach them. 
Cystic polypi can be punctured with an aspirator needle, or a 
small trocar, and their contents drawn off. 

It is occasionally possible to push the tumor above the 




Fig. 219.— Multiple Fibroid Developments on the Gravid Uterus. 

(Charpentier.) 

pelvic brim, out of the way of the presenting part, as has been 
demonstrated in numerous instances. This is sometimes prac- 
ticable even where the conditions are extremely unfavorable. 
Mr. Spencer Wells relates a case wherein he was called to per- 
form Csesarean section, but succeeded in pushing the obstruct- 
ing tumor above the brim, whereupon the foetus passed with 
ease. Persistent effort, and considerable force, may be employed, 
when the impending dangers to both mother and child warrant 
the procedure. Before we attempt to operate, the woman 
should be deeply anesthetized. 

If the tumor is hard, and cannot be pushed above the brim, 



Parturient Anomalies. 



475 



the next operations for consideration are enucleation and abla- 
tion. Such growths usually have loose attachments, and, when 
within reach, can often be enucleated. If this procedure is im- 
practicable, they may be twisted off, or removed with the 
ecraseur. Should neither of these operations be deemed ex- 
pedient, the character of further treatment will be determined 
by the amount of obstruction, the operations in their order 
being forceps delivery, craniotomy, and abdominal section. 




Fig. 220. — Labor impeded by uterine Polypus. 



Hemorrhage after delivery has generally been regarded in 
these cases as strongly menacing, but fortunately it is not so 
common as might be expected. 

Tumors of the Ovary Obstructing Delivery.— An ovarian 
tumor of considerable size cannot descend into the pelvic 
cavity, and hence will not become a serious obstacle to delivery. 
Those tumors which really do encroach upon the space which 
forms the parturient canal, are such as have previously at- 
tracted little or no attention. 

We should distinguish between cysts containing fluid, and 
those with only solid matters. If the character of the tumor is 



476 



Labor. 



doubtful, no serious injury will be inflicted by an exploratory 
puncture with a fine aspirator needle, or small trocar. Playfair 
collected and tabulated fifty-seven cases of ovarian tumor 
obstructing labor, with the following results : In thirteen, labor 
was terminated by the unaided natural powers, but of this 
number six mothers died. With these he contrasts nine cases 
in which the tumor was diminished by puncture. The mothers 
all lived, and six out of the nine children were saved. "The rea- 
son," he says, "of the great mortality in the former cases is 
apparently the bruising to which the tumor, even when small 
enough to allow the child to be squeezed past it, is necessarily 
subjected. This is extremely apt to set up a fatal form of 
diffuse inflammation, the risk of which was long ago pointed 

out by Ash well, who 
draws a comparison 
between cases in which 
such tumors have been 
subjected to contusion, 
and strangulated her- 
nia ; and the cause of 
death in both is doubt- 
less very similar. This 
danger is avoided when 
the turn or is punctured^ 
so as to become flat- 
tened between the head 
and the pelvic walls. 
On this account, I 
think, it should be laid 
down as a rule, that puncture should be performed in all 
cases of ovarian tumor engaged in front of the presenting part, 
even when it is of so small a size as not to preclude the possi- 
bility of delivery by the natural powers." 

In five of the fifty-seven cases, the tumor was pushed above 
the pelvic brim, and the termination was in every instance in 
maternal recovery. It is a wise procedure, in all those cases 
where the contents of the sac cannot be evacuated by puncture, 
to make a persistent, yet not harsh, attempt to return the 
tumor to a situation above the pelvic inlet. Such treatment 
will sometimes succeed even under unpromising conditions. 

Should both puncture and reposition fail, or be out of the 
question, craniotomy would be preferable to any attempt at 




Fig. 221.— Labor obstructed by ovarian 
Tumor. 



Parturient Anomalies. 477 

delivery with the forceps. In extreme cases, abdominal section 
may be the only mode of extraction. 

Rigidity of the Perineum.— Rigid os uteri has sometimes 
associated with it, and augmenting parturient dangers and dif- 
ficulties, a rigidity of the perineum, which owes its existence to 
a like cause. In most instances, the hardness is gradually over- 
come, and the perineum escapes without serious laceration ; but 
sometimes the contraction is unyielding, and rupture the conse- 
quence. In general, the structures of the pelvic floor and outlet 
are softened during labor, by physiological processes, into a con- 
dition of elasticity and ductility, and the perineum yields before 
the advancing head, to the necessary degree, without much 
solution of continuity. On the contrary, we find that, in some 
instances, such softening does not take place, and, at the ex- 
pense of structural integrity, the foetus is allowed to pass. The 
latter condition is most frequently observed in primiparse, and, 
hence, perineal rupture most frequently occurs in first labors. 
It is especially true of aged primiparse, in whom there is usu- 
ally a non-elasticity of the soft structures, uncommon in 
younger women. Old cicatrices, the results of former lacera- 
tion, may impart a firmness to the perineum exceedingly un- 
friendly to its preservation. 



478 



Labor. 



CHAPTER XII. 

PARTURIENT ANOMALIES REFERABLE TO THE MATERNAL 
OSSEOUS STRUCTURES. 

Deformities of the Pelvis.— Without following closely the 
usual classification of deformed pelves, we shall consider, under 
the above title, deviations from the common form and size, 
whether the dimensions of the pelvic canal are uniformly 
changed, or are contracted in particular diameters. 

Large Pelvis. — While the difficulties and pains of labor are 
considerably diminished in the case of enlarged pelves, the dan- 
gers are not correspondingly reduced. Mere facility of expul- 
sion is not the most im- 

ii 



portant consideration in 
connection with labor. 
When the pelvis is too 
roomy, dangers and 
complications of a dif- 
ferent sort are liable to 
arise. These are such as 
accompany precipitate 
labor in general, and 
consist mainly of a drag- 
ging or forcing down- 
wards of the entire 
uterus, from want of proper resistance of the pelvic walls, and 
hence rapid distension of the soft structures, with the conse- 
quent occurrence of cervical and perineal laceration. Among 
the dangers may also be mentioned strain and rupture of the 
cord from sudden expulsion of the foetus with the woman in 
the erect posture, and uterine inversion. 

Symmetrically Contracted Pelvis, or Pelvis ^Equabili- 
ter Justo-Minor.— The general form of the pelvis may be sym- 
metrical, the relative diameters remaining unchanged, but the 
structure small from equable contraction of all its diameters. 
These conditions constitute one of the most formidable ob- 
stacles to delivery. Fortunately such pelves are rarely met. 
They present an infantile type, and are doubtless occasioned 
by premature arrest of osseous development. 

Flattened Pelvis.— The peculiarity of this form of pelvis 




Fig. 



-The Flattened (Rachitic) Pelvis. 



Parturient Anomalies. 



479 



is its shortened conjugate diameter. The transverse measure- 
ment remains nearly or quite normal. 

There are two varieties, differentiated by the causes which 
unite in their production. The non-rachitic form is the most 
frequent of all. The general conformation, as well as the indi- 
vidual bones, of such pelves are frail. The sacrum is depressed 
and pushed inwards between the two ilia, making the promon- 
tory still more prominent. A great degree of contraction is 
uncommon, the conjugate diameter rarely falling below three 
inches. 

The cause of this deformity is not well understood. Lifting 
and carrying heavy burdens in early childhood, incompletely 
developed rickets, and retarded development, are regarded as 
sharing in its pro- 
duction. 

In the rachitic 
form of flattened 
pelvis the bones 
are generally 
rather small, but 
sometimes com- 
pact and thick- 
ened. The ilia are 
flattened and 
spread. The sa- 
cral promontory 
is thrown inwards 
towards the pubic 
symphysis, and the base of the sacrum depressed between the 
ilia. The sacrum has a sharp curve forwards, at or about the 
fourth vertebra. The sacrum also loses its side to side curve. 
The transverse diameter of the brim is about normal. The 
horizontal rami of the pubes are flattened, and the acetabula 
are turned forwards. The ischia are spread, and hence the 
pubic arch is widened. Such a pelvis is contracted at the brim, 
and widened at the outlet, while its depth is diminished. De- 
pression of the sacrum is plainly observable. 

The proximate cause of these deformities is traceable mainly 
to the weight of the superimposed body on the pliable bones. 
Some of the changes, however, are probably congenital, some 
due to muscular action, and others to disturbances of growth 
and persistence of the foetal type. 




Fig. 223.— Malacosteon Pelvis. 



480 



IAbor. 



Flattened, Generally Contracted, Pelvis.— This variety 
closely resembles the justo-minor pelvis, and, during life, is not 
often distinguishable from it. The deformity is most frequently 
due to rachitis. 

Irregular Rachitic and Malacosteon Pelvis.— Rickets 
usually comes on before the child has begun to walk, and the 
weight of the body is thrown on the ischia instead of the aceta- 
bula. Malacosteon begins later in life, and the weight of the 
whole trunk is transmitted to the thigh bones through the 
acetabula. As a result of these varying conditions, a decided 
difference in the character of pelvic distortion is observed. 




Fig. 224.— Obliquely-distorted Pelvis. 



The most frequent of all the varieties of rachitic pelvis is that 
wherein the conjugate diameter of the brim is shortened by pro- 
jection forwards of the sacral promontory, accompanied, or 
not, by depression of the pubes. Different varieties of distortion 
have been described, such as ''masculine," "heart-shaped," and 
"figure of eight" deformities of the brim, all of them, however, 
preserving the general elliptical form. 

In the malacosteon pelvis the general form is angular, occa- 
sioned by the depressions at the acetabula, growing out of the 
conditions before mentioned. 



Parturient Anomalies. 



481 



The characters of these two varieties of deformity are often 
blended. "These are," says Leishman, "mere illustrations of 
possible variations, which might be infinitely multiplied; but 
it is to be remembered that a considerable number of cases have 
been met with in which an undoubtedly rickety pelvis presented 
all the more prominent characteristics of malacosteon de- 
formity." He also adds: "In so far as the true malacosteon 
pelvis is concerned, it has been well observed by Stanley that 
there is no diminution in the actual circumferential measure- 
ment of the brim, and that the bones are of their natural bulk 
and proportion, so that if their various doublings were unfolded, 
the pelvis would be restored to its normal dimensions and 





Fig. 225.— Flattening of the Sacrum. 



Fig. 226.— Exaggerated Sacral 
Curve. 



form. In rickets, however, this does not usually apply, owing,, 
as has already been observed, to the partial arrest of develop- 
ment which obtains during the course of the disease." 

Oblique Oval Pelvis. — This distortion essentially consists 
in a deficient development and flattening of one side of the 
pelvis, of an anchylosis of the sacro-iliac joint of the same side, 
and of a depression of the sacrum towards the latter, while the 
symphysis pubis is thereby displaced so as to be nearly opposite 
the sacro-iliac synchondrosis of the sound side. 

" Most of the cases of obliquely-contracted pelvis," says Hirst, 
"have been diagnosed after death; the entire number of cases 
observed is given as about fifty, but probably this is too small." 
Zweifel states that with a great difference between the two sides 
of the pelvis the diagnosis during life cannot be difiicult. 
(31) 



482 



Labor. 



Should there be delay during labor in the entrance of the head 
into the pelvis, the possibility of this deformity will be 
suspected if we find it impossible to reach the sacral prom- 
ontory. 

Flattening of the Sacrum.— A relatively more common 
form of pelvic deformity, sometimes associated with other dis- 
tortions, and again existing independently of them, is flattening 
of the sacrum. On account of such a deformity, the head may 
become incarcerated in the pelvic cavity, and occasion much 
difficulty in delivery. 

Exaggerated Curve of the Sacrum. — The condition oppo- 
site to that just described is occasionally observed, consisting 
of an exaggeration of the sacral curve. 




Fig. 227.— Kobert's Pelvis. 



Fig. 228.— Spondylolisthetic Pelvis. 



Funnel-Shape Pelvis. — What has been termed the "funnel- 
shaped" pelvis, in its general appearance bears quite a resem- 
blance to the male pelvis. In such a specimen the diameters of 
the pelvic canal diminish from above downwards, and the head, 
when driven into such a pelvis, is liable to become impacted. 
Pelvic presentation in a pelvis thus deformed is almost invari- 
ably fatal to the child. 

Infantile Type of Pelvis. — From arrest of development, 
the pelvis occasionally preserves its infantile form, presenting a 
greater inclination of the brim, and a relatively great conjugate 
diameter. 

Deformities from Spinal Curvature.— The shape of the 
pelvis is considerably modified by spinal curvature, especially 
in those cases which originate in infancy or childhood. Thus 
both kyphosis and scoliosis have their peculiar pelvic modifi- 
cations. 



Parturient Anomalies. 



483 



The Anchylotic, Transversely-Contracted Pelvis.— In 
this form of pelvis the antero-posterior diameter is either 
normal or somewhat increased in its dimensions, while the 
transverse diameter, and especially that of the outlet, is dimin- 
ished. At the same time there are bilateral sacro-iliac anchy- 
losis, and absence, or rudimentary development, of the sacral 
alge. The sacrum is narrow, especially at the base, and both its 
longitudinal and transverse concavities are nearly obliterated. 
This bone is also depressed, and its promontory is tilted for- 
wards. The ilia are flattened, the descending rami of the pubes 
unite at an acute augle, and the ischial tuberosities are ap- 
proximated. These changes decidedly increase the pelvic 
depth. 

The cause of these peculiar modi- 
fications of form is probably found 
in arrested or imperfect develop- 
ment of the sacrum, followed by 
anchylosis of the sacro-iliac joints. 

This is known as Kobert's pel- 
vis, because first described by 
Kobert in 1842. 

Spondylolisthetic Pelvis. — 
This is a rare form of pelvic de- 
formity, and consists chiefly in 
separation of the last lumbar ver- 
tebra from the sacral base, and 
descent of the lumbar spine into 
the pelvis, as shown in the ac- 
companying cut, thereby greatly reducing the conjugate 
diameter. The patient's history will reveal an injury in in- 
fancy. 

Osteo-Sarcoma and Exostosis.— These growths are of com- 
paratively frequent occurrence. They originate from any part 
of the osseous tissue of the pelvis, but seem to prefer the upper 
third of the sacrum. The proportions which such a growth 
may attain are w T ell shown in the accompanying figure. Pelves 
which present these growths are most frequently of the oblique- 
ovate, or of the rachitic variety. 

Other Osseous Tumors and Projections.— Pelvic deformity 
may result from fractures of the pelvic bones, either by perma- 
nent displacement, or by the formation of extensive, or numer- 
ous, deposits of callus. 




Fig. 229.— Pelvic Exostosis. 



484 Labor. 

Cancerous disease, producing tumors of some size and con- 
sistency, may offer serious obstructions to labor. Their 
development is not confined to any particular part of the pelvic 
structure. 

Osseous spiculae sometimes exist, especially at the margins of 
the various pelvic articulations. The ilio-pectineal eminences, 
and the pubic crest and spine, may be prolonged and sharp. 
Such malformations are apt not only to impede labor, bub to 
create uterine laceration. 

Absence of the Symphysis.— This rare form of pelvic de- 
formity, termed "split pelvis" by Litzmann, consists in con- 
genital absence of the symphysis, its place being filled by strong 
fibrous bands extending between the opposed surfaces of the 
pubic bones, or by the muscles and connective tissue of the 
perineum. 

The Chief Causes of Pelvic Deformity.— The diseases which 
constitute the main predisposing causes of pelvic deiormity are 
Kachitis, or Rickets, and Malacosteon, or Osteomalacia. 

Rachitis, as we have said, is a disease of infancy, developed 
most frequently during the latter half of the first year of life. 
It very rarely appears after the establishment of puberty. It 
is essentially a disease of perverted nutrition, affecting nearly 
every tissue of the body, but chiefly and most constantly char- 
acterized by a softening of bone, with resulting deformities. 
The osseous structures are markedly deficient in earthy salts, 
and the animal matter seems in some respects abnormal. The 
epiphyses are enlarged, and ossification at these points goes on 
in an irregular manner. The resulting deformities are not 
limited to any particular part of the body, but are most dis- 
tinct in the long bones, the pelvic structures, and the spine. 

The disease usually ends in recovery, but the resulting de- 
formities, though sometimes modified by time, forever remain. 

Malacosteon is in this county a rare disease. While it 
agrees with rachitis in the particular of bone-softening, it differs 
in the fact that it is a disease of adult, rather than of infantile, 
life. Its development usually begins in the puerperal stage, and 
is slowly progressive, each added pregnancy giving new impetus 
to the pathological changes. 

The effects of the disease may be observed throughout the 
body, or they may be confined to individual bones. The pelvis and 
vertebrae are occasionally the only parts which suffer, especially 
when the disease develops in the puerperal state. According to 



Parturient Anomalies. 485 

Schroeder, the disease is regarded as an osteomyelitis, which, 
beginning in the center of bones, advances towards the pe- 
riphery, the essential pathological processes consisting in the 
absorption of calcareous matter through the Haversian canals, 
and the substitution of hypertrophic medullary tissue for the 
softened osseous structures. The result is that the bones 
become pliable and elastic, like rubber, and, eventually, even of 
wax- like softness. 

But there are other causes of pelvic deformity, among which 
may be mentioned pelvic fracture with permanent displacement 
of all the bones; also the late establishment of puberty. Until the 
age of fourteen or fifteen years, the pelvis of the female differs 
in shape but slightly, if at all, from that of the male ; but, as 
soon as the girl has her first menstrual flow, the pelvis begins 
to expand. If the appearance of menstruation is deferred to 
the age of seventeen, eighteen or twenty, the bones of the pelvis 
having become firmer, and the articulations anchylosed, with- 
out the pelvis having taken on feminine characteristics, the 
anomalies of form become permanent. 

Diagnosis.— A positive diagnosis of pelvic deformity can be 
based only on a direct examination ; but valuable data which 
point to such a condition may be gleaned from inspection, and 
the previous history of the woman. When the infantile experi- 
ences were such as usually accompany rachitis, and especially if 
there are patent physical deformities which may reasonably be 
attributed to such causes, the case should be regarded with 
suspicion. 

The history of previous labors will throw some light on the 
subject, and, if there were connected with these great difficulties 
and much suffering, we should suspect pelvic contraction as a 
contributing cause, and accordingly institute most thorough 
exploration. 

The special appearances of the woman, unassociated with 
her history, may lend a strong probability to pelvic deformity. 
These are, briefly, a square head, pigeon-breast, small stature, 
spinal curvature, enlarged joints, and incurvation of the long 
bones of the extremities. 

Exact measurements can be made only by means of instru- 
ments constructed for the purpose, termed pelvimeters. Numer- 
ous patterns have been devised, some of which are intended for 
external, and others for internal measurements, while some are 
designed for either mode of use. The internal dimensions are 



486 Labor. 

those sought, no matter whether they be ascertained directly 
by measuring the cavity, or indirectly, and less accurately, by 
ascertaining the external size, and making allowance for the 
thickness of the pelvic walls. 

In nearly all forms of pelvic distortion, the conjugate diam- 
eter is the one which is most contracted, and, hence, the instru- 
ments which have been devised, and the efforts which are 
generally made, have for their more especial object the deter- 
mination of that measurement. 

For external use, Baudelocque's calipers is probably the 
instrument in most common use, though Schultze's is much 
employed. For internal use Coutonly's, Earle's and Green- 
halgh's are among the most prominent. 

While it is only by means of such instruments that accurate 
measurements can be taken, practical ends will be well served by 
what has been termed manual pelvimetry. For the purpose of 
ascertaining the conjugate diameter of the brim, one or more 
fingers are introduced, and the point of the index or the middle 
finger is made to touch the sacral promontory, while the depth 
of penetration is marked by the thumb of the same hand, or by 
the finger of the opposite one. The fingers are then withdrawn, 
and the depth of introduction measured. A subtraction from 
this of half an inch is supposed to give the approximate conju- 
gate diameter. 

The transverse and oblique diameters of the brim may be 
approximately determined by introducing the four fingers of 
one hand and spreading them. 

No special directions are required to determine the diameters 
of the pelvic outlet, as they are so immediately under visual 
and tactual survey. 

Concerning pelvimetry, DepauLwell says : " Notwithstanding 
the partial advantages offered by the pelvimeters, they one and 
all are open to objections which render them useless in routine 
practice. Of all the methods of measurement, that by the hand 
is certainly the least uncertain, inconvenient, and most exact 
in its results. We may thus measure the conjugate, and ap- 
preciate with sufficient exactness the length of the transverse 
and of the oblique diameters of the superior strait; all the 
more readily, of course, in the cavity, and at the inferior strait. 
Further, thus exostoses and tumors may be readily recognized. 
This is the method of mensuration almost entirely used in 
France, and abroad the tendency is to return to it. We cer- 



Parturient Anomalies. 



487 



tainly do not thus attain mathematical results, but the expert 
obtains figures precise enough for practical purposes." 

Influence of Pelvic Contraction on the Uterus During 
Pregnancy.— In the early months of pregnancy the contracted 
pelvis favors dislocation of the uterus backwards. It is held 
down by the unusual projection of the sacral promontory, and 
a version is ultimately transformed into a flexion. 

In the latter months, pelvic contraction, by preventing the 
customary descent of the lower uterine segment below the 
pelvic brim, maintains the organ in an unusually high situa- 
tion, and therefore crowds the fundus hard against the 




Fig. 230.— Manual Pelvimetry. (Zweifel). 

stomach, as a result of which pendulous abdomen is sometimes 
produced. 

Influence of Pelvic Contraction on Foetal Presenta- 
tion.— Faulty presentations are relatively frequent in pelvic 
deformity. The following data gathered by Charpentier from 
Litzmann, Spiegelberg, Schrceder and Stanesco, give us a 
pretty clear idea of the frequency of the various presentations 
in this class of cases. 



( Vertex, . 
In 108 cases where spontaneous labor occurred < ^ reecn ' • 

I Shoulder, 
In 47 cases where labor was ended by version -j Shoulder, 



92 
13 
2 
1 
31 
11 



488 



Labor. 



Vertex, 
In 108 cases where labor was ended by forceps -J Face, 

Breech, 

{Vertex 
Breech,' 
Face, 



In 46 cases premature labor was induced 

In 90 where cephalotripsy was requisite 

In 4 Cesarean sections 

In 414 cases, then : 

Vertex, . 

Face, 

Breech, 

Shoulder, 

Not stated, 



Vertex, 

Breech, 

Shoulder, 

Vertex, 

Face, 

Breech, 

Vertex, 

Not stated, 



102 

5 

1 

13 

2 

1 

34 

8 
4 
82 
4 
4 
2 
2 



336 

12 
28 
36 

2 



Eigaud in 396 cases, with 404 children, gives the following figures : 

fO.L.A., . . 352 
Presentations of vertex . . . . < o'r'a"' 6 

IO.L.P.',' '. '. 2 

The position O.L.A. includes the cases where the presentation was noted 
and the position not. 

Breech cases, 29 

Face, .4 

Shoulder, ... 11 

Considering together the statistics of Eigaud and of Stanesco : 

Infants. 

Presentations of vertex, 696 

" face, .17 

" breech, 67 

'' shoulder, . . . . . .47 

" " unknown, ..... 2 



Total, 



829 



Influence of Pelvic Contraction on Labor-pains.— When 
insurmountable obstacles are encountered by the natural 
forces, the uterus, from the vehemence of its contractions, is 
extremely liable to rupture. There is also unusual danger of 
the organ tearing itself loose from the vagina by its excessive 
retraction. After a time, in most cases, muscular action becomes 
weak, and lingering labor results. 

Influence of Pelvic Contraction on the First Stage of 
Labor. — At the beginning of labor the head is high and the 



Parturient Anomalies. 489 

lower uterine segment protrudes empty through the brim. The 
liquor amnii is driven downwards with force, but still the os 
dilates very slowly. The membranes are apt to break prema- 
turely, when the os and cervix, which had been somewhat dis- 
tended by the bag of waters, now relieved of dilative pressure 
seem again to contract. If the pelvic deformity be too great 
to allow the head to descend, the pains continuing, and help 
being deferred, some form of uterine laceration can hardly be 
escaped. 

Effect of Pressure on the Soft Pelvic Tissues.— The 
foetal head is the only part which is capable of producing in- 
jurious pressure, unless the arrest should extend over a long 
period. In contracted pelves the most severe injuries are re- 
ceived at the brim. When the promontory is unusually promi- 
nent, and when there are spiculse, or other irregular points of 
pressure, the uterine tissues, which in the first stage lie between 
the head and the brim, are often crushed and thinned, and, at 
times, even perforated and torn. 

Effect of Pressure on the Child's Head.— The tumor 
formed on the fcetal cranium (caput succedaneum) is often large 
and bloody, and varies in location and form with the position 
and character of the contraction. The head also presents 
localized pressure marks, derived in most cases from the jutting 
promontory. If the pressure is not severe, the mere reddish 
lines which result will soon disappear, but in other cases they 
may be so deep and broad as to result in considerable destruc- 
tion of tissue. These marks are commonly found on the 
parietal bones, since it is the biparietal diameter which in such 
cases is thrown into the pelvic conjugate. 

Prognosis.— Prognosis will, of course, depend upon the de- 
gree of deformity present. If the diameters are but slightly 
diminished, parturition may be tedious and laborious, but 
neither the maternal nor fcetal risk is greatly increased ; but if 
the deformity is considerable, the prognosis must be corre- 
spondingly grave. The maternal mortality in these cases is at 
least twice as great as in normal pelves. The fcetal mortality 
is excessive. Combining the statistical tables of Stanesco and 
Rigaud we have a total of 667 cases which show the following 
results : 

In pelves measuring 3.5 in conjugate diameter of the brim — 
301 cases: Maternal mortality, 19.3; fcetal mortality, 25.33. 

In pelves measuring from 3.5 to 3.1 in the conjugate of the 



490 Labor. 

brim,— 215 cases : Maternal mortality, 18.61 ; foetal mortality, 
48.37. ' 

In pelves measuring from 2.7 to 2.3 in the conjugate of the 
brim,— 93 cases : Maternal mortality, 22.60; foetal mortality, 
62.36. 

In pelves measuring from 2.7 to 2.3 in the conjugate of the 
brim,— 42 cases: Maternal mortality, 42.80; foetal mortality, 
90.5. 

In pelves measuring from 2.3 to 1.9 in the conjugate of the 
brim,— 16 cases: Maternal mortality, 50.00; foetal mortality, 
68.75. 

Treatment. — Treatment of these cases involves not only 
the question of proper management after labor has set in, but 
also the question of advisability, in individual cases, of bring- 
ing about abortion or premature labor. 

Induction of Abortion in Extreme Deformity. — When the 
contraction is so excessive that a viable child, of average size, 
cannot be safely delivered, early abortion should be induced. 
The foetal life, in such a case, would not weigh a grain in the 
balance, since the possibility of preserving it is out of the ques- 
tion, and we are left to act in the interest of the mother only. 
Nothing can be gained from delay, and hence the dictates of 
wisdom would lead us to artificial interruption of pregnancy 
as soon as possible after its existence becomes manifest. There 
is no amount of deformity which can prevent the successful 
adoption of some of the means for its accomplishment placed 
at our disposal. 

The Induction of Premature Labor in Deformed Pelves. 
— "The induction of premature labor," says Playfair, "as a 
means of avoiding the risks of delivery at term, and of possibly 
saving the life of the child, must now be studied. The estab- 
lished rule in this country (England) is, that in all cases of pelvic 
deformity, the existence of which has been ascertained either by 
the experience of former labors, or by accurate examination of 
the pelvis, labor should be induced previous to the full period, 
so that the smaller and more compressible head of the prema- 
ture foetus may pass, where that of the foetus at term could not. 
The gain is a double one, partly the lessened risk to the mother, 
and partly the chance of saving the child's life. 

"The practice is so thoroughly recognized as a conservative 
and judicious one, that it might be deemed unnecessary to 
argue in its favor, were it not that some most eminent authori- 



Parturient Anomalies. 491 

<■ 

ties have of late years tried to show that it is better'and safer 

to the mother to have the labor come on at term, and that the 
risk to the child is so great in artificially induced labor as to 
lead to the conclusion that the operation should be altogether 
abandoned, except, perhaps, in the extreme distortion in which 
the Csesarean section might otherwise be necessary. Prominent 
among those who hold these views are Spiegelberg and Litz- 
mann, and they have been supported, in a modified form, by 
Matthews Duncan. Spiegelberg tries to show, by a collection of 
cases, from various sources, that the results of induced labor 
in contracted pelvis are much more unfavorable than when the 
cases are left to nature ; that in the latter the mortality of the 
mothers is 6.6 per cent., and of the children 28.7 per cent., 
whereas in the former the maternal deaths are 15 per cent., and 
the infantile 66.9 per cent. Litzmann arrives at not very dis- 
similar results, namely, 6.9 per cent, of the mothers, and 20.3 
per cent, of the children in contracted pelvis at term, and 14.7 
per cent, of the mothers, and 55.8 per cent, of the children, in 
artificially induced premature labor. 

"If these statistics were reliable, inasmuch as they show a 
very decided risk to the mother, there might be great force in the 
argument that it would be better to leave the cases to run the 
chance of delivery at term. It is, however, very questionable 
whether they can be taken, in themselves, as being sufficient to 
settle the question. The fallacy of determining such points by 
a mass of heterogeneous cases, collected together without a 
careful sifting of their histories, has over and over again been 
pointed out; and it would be easy enough to meet them by an 
equal catalogue of cases in which the maternal mortality is al- 
most nil. The results of the practice of many authorities are 
given in Churchill's works, where we find, for example, that out 
of 46 cases of Merriman's, not one proved fatal. The same for- 
tunate result happened in 62 cases of Ramsbotham's. His con- 
clusion is, that ' there is undoubtedly some risk incurred by the 
mother, but not more than by accidental premature labor,' and 
this conclusion, as regards the mother, is that which has long 
ago been arrived at by the majority of British obstetricians, 
who undoubtedly have more experience of the operation than 
those of any other nation. With regard to the child, even if 
the German statistics be taken as reliable, they would hardly 
be accepted as contraindicating the operation, inasmuch as it 
is intended to save the mother from the dangers of the more 



492 Labor. 

serious labor at term, and, in many cases, to give at least a 
chance to the child, whose life would otherwise be entirely sacri- 
ficed. The result, moreover, must depend to a great extent on 
the method of operation adopted, for many of the plans of 
inducing labor recommended are certainly, in themselves, not 
devoid of danger, both to the mother and the child. It may, 1 
think, be admitted, as Duncan contends, that the operation 
has been more often performed than is absolutely necessary, 
and that the higher degrees of pelvic contraction are much 
more uncommon than has been supposed to be the case. That 
is a very valid reason for insisting on a careful and accurate 
diagnosis, but not for rejecting an operation which has so long 
been an established and favorite resource." The ideas of 
American obstetricians do not materially differ. 

When to Induce Premature Labor.— The operation once 
decided upon, the period at which premature labor should be 
induced is a matter of the greatest importance. The tables 
which have been prepared to direct the physician in fixing upon 
the suitable time, while theoretically clear and precise, are of 
less value than we might expect them to be, because of the 
exceeding difficulty in estimating with accuracy the actual 
amount of contraction which exists in different cases. The table 
prepared by Kiwisch, which appears in various text-books on 
obstetrics, is as valuable as any : 

Inches. Lines. 
When the sacro-pubic diameter is 2, and 6 or 7, induce labor at 30th week. 



2, 


" 8 or 9, 


< a 


31st ' 


2, 


" 10 or 11, 


i a 


32d 


3, 


a 


l u 


33d 


« 


3, 


" 1 


i u 


33d 


3, 


" 2 or 3, 


i M 


34th ' 


3, 


" 4 or 5, ' 


( U 


35th ' 


3, 


" 5 or 6, ' 


I It 


36th ' 



When expulsive action has been evoked, the treatment should 
be like that of labor spontaneously begun. In most instances 
the natural forces will be found adequate to the emergency; 
but in others the forceps, or turning, may be called for. As 
the result of most deliberate and judicious treatment, these 
cases may, in a large percentage of cases, be carried onwards to 
a conclusion favorable alike to mother and child. 

When the conjugate of the brim is below two and three- 
fourths inches, the chances of saving the child by premature 
labor are too slight to be considered. Barnes proposed in some 



Parturient Anomalies. 493 

cases to perform version in premature labor, especially if the 
pelvis measures less than three inches, and it has since been 
successfully done in many cases. 

"A Substitute for Premature Delivery. — There are few general 
practitioners who have not found it necessary to bring on pre- 
mature labor in cases of moderately narrowed pelvis. The 
idea of never being able to bear a living child is one that 
weighs heavily upon the unhappy subject of such malformation 
as will prevent the proper fruition of the marriage contract. 
The stigma attached to such incompetency is felt keenly by 
all right-minded women, and the attending physician is 
oftentimes worried by both wife and husband to bring on pre- 
mature labor, and yet try to so gauge the time that a viable 
child may be born to them. This is a proceeding which, though 
often necessary, can never be undertaken without some hesi- 
tancy on the part of the attendant. Csesarean section is as 
yet, notwithstanding the freedom displayed by laparotomists 
in exploring the abdomen, too dangerous a procedure to tempt 
either parent or surgeon to permit gestation to go on to full 
term, knowing that a living child cannot be born by the natural 
outlet. We have noticed from time to time methods pursued, 
in the feeding of parturient women, with the avowed object of 
rendering the bony structures of the child more yielding, so 
that the head would be more easily molded and expelled. Not 
much attention has been paid to such measures in this country, 
and, indeed, to the ordinary medical mind, the idea seems 
rather far-fetched, and not exactly scientific. 

" Lately, however, some attention has been paid to this sub- 
ject in Germany. T. Prochownick, of Hamburg, has been 
working in this line, and now lays down a dietary for such 
cases. His idea is that the child should be as free as possible 
from adipose tissue, yet still strong and well developed. By this 
method he has been able to bring to a successful termination, 
at full term, three pregnancies, although the pelvis was in each 
case very narrow. The children were strong and fully matured, 
but of very light weight. We regret that the actual measure- 
ments of the pelves spoken of are not given. It seems certain, 
however, that ordinary children could not have been born in 
either of the three cases. 

"The diet, which was carried out for about six weeks preced- 
ing the time of the expected confinement, was as follows: 
Breakfast—A small cup of coffee, with a one-ounce roll ; Dinner 



494 Labor. 

—any kind of meat, eggs, fish with but little sauce, a little 
'greens,' cheese; supper— about the same list as for dinner, 
with the addition of one and one-half to two ounces of bread, 
with butter as desired. 

"The following are forbidden: Water, soup, potatoes, 
starchy foods, sugar and beer. For drink the patient is allowed 
from ten to fourteen ounces of red or Moselle wine daily. In 
this manner, which demands only a little strength of will on 
the part of the mother, the author hopes to obtain mature, 
healthy children, possessing some stock of resistance, in cases 
where the induction of premature labor would be otherwise un- 
avoidable. Besides the general lack of adipose tissue in the 
three children mentioned, it was found that the cranial bones 
were more easily compressible beneath the thin and wrinkled 
scalp, and on this account the progress of the labor was ren- 
dered more favorable both for mother and child. After birth 
the emaciated appearance of the child was rapidly dissipated 
by the formation of the normal layer of fat." 

When is Interference During Labor Advisable ?— When 
labor has once set in, it becomes necessary, after a time, to de- 
cide upon the proper moment at which to adopt operative 
measures for the woman's relief. In the minor degrees of pelvic 
deformity, it is always proper to give nature a fair opportu- 
nity ; but, if the uterine efforts are extremely violent, we should 
be careful not to allow the case to progress to the point of ex- 
haustion. When the head is small, or the cranial bones unusu- 
ally pliable, it sometimes happens, even in unpromising cases, 
that the head becomes so molded as to pass with perfect safety 
to both mother and child. 

Cases Wherein Delivery of a Living Child at Full Term, 
Through the Natural Passages, is Possible. — In this category 
we mean to include flattened pelves with a conjugate of three 
inches and over, and justo-minor pelves with a conjugate of 
over three and a third inches. Below these figures, delivery of 
living children is rarely, if ever, possible. Our resources here 
are forceps and version. 

In labor at full term the membranes must be most tenderly 
cared for in order to prevent rupture prior to fair dilatation of 
the os uteri. Obliquities of the uterus should be considered, and 
postural and other treatment resorted to for their correction. 
The pains should be stimulated when weak, and soothed when 
too strong. If after escape of the liquor amnii and close of the 



Parturient Anomalies. 



495 



first stage the head still refuse to engage the pelvic brim, the 
disproportion may usually be reckoned as considerable. Use of 
the forceps on a head which is too large to become engaged in 
the pelvic brim is hazardous even in the most skillful hands, and 
to be adopted with the utmost caution.* We should give the 
natural efforts a fair opportunity, and if the head finally be- 
comes fixed at the brim, the forceps may be employed with every 
prospect of success. If nature be unable to accomplish fixation 
within a reasonable time, of which the physician must be his 
own judge, we may still use the forceps if the conditions seem 
friendly to such a mode of delivery, or we may have recourse 
to version. 

Version. — Before deciding upon version we should be sure 
that the child is living, because the operation is to be made in 
its behalf. If it be found dead, perforation is the suitable 





Figs. 231 and 232.— Change of Cephalic Form, from molding, in difficult 

head-last cases. 

treatment. Version is indicated only when the foetal heart 
pulsates with vigor, and the pelvis measures between two and 
three-quarters and three and one-half inches in the conjugate, 
with progressively increasing dimensions towards the outlet, 
and with an ample transverse diameter. The advantages de- 
rivable from turning in such cases have been set forth by Sir 
Jas. Simpson, and his views have been sustained by others. 

It is but the revival of an old operation, but with its limits 
clearly defined, and its advantages perspicuously set forth. 
Simpson shows that the head viewed in transverse section is 
cone-shaped, its narrowest portion being at the base, repre- 



* Dr. H. Williams has collected 119 cases reported since 1858, where the forcers were 
applied to the head above the brim, and finds that nearly forty per cent, of the mothers, 
and over sixty per cent, of the children, perished. We have had experience in four or 
five such cases, in which delivery of a dead foetus was ultimately effected by means of 
version, but the mothers were fortunate enough to escape. 



496 



Labor. 



sented by the bi-temporal diameter, and its widest part above, 
represented by the bi-parietal diameter ; the variation in diam- 
eters being from one-half to two-thirds of an inch. When the 
vertex presents, the broader part is in advance, and if the pelvic 
diameters are shortened, much greater force and much longer 
time will be required to drive the head through, than in cases 
of pelvic presentation, in which the lesser diameters descend in 
advance. Indeed, he shows that, in some cases, nature may 
utterly fail to drive the head through a contracted brim, and 
yet delivery be safely accomplished by version, with greater ease 
and less danger than by the forceps. 

Other advocates of the operation, by further elucidation of 
the subject and the clinical application of these theories, have 

shown that it is possible 
to deliver a living child by 
turning through a pelvis 
contracted beyond the point 
which would permit a living 
child to be extracted by the 
forceps. Goodell, and some 
others, assure us that a liv- 
ing child may be delivered 
by version through a pelvis 
with a conjugate diameter 
of two and three-quarters 
inches, but other obstetri- 
cians of extensive experi- 
ence, as, for example, Barnes, set the limits of the operation at 
from three and one-fourth inches upwards. 

From a consideration of all the arguments advanced on both 
sides of the question, and the clinical cases reported, it appears 
to be an established fact, that delivery of a living child may be 
accomplished in some cases of pelvic contraction, wherein both 
nature and the forceps have proved inadequate to the task. 

We should not lose sight of another advantage to be derived 
from turning in such cases, namely, that pressure on the head 
at the brim, in the supra-pubic space, may be exercised by an 
assistant, and extraction thereby greatly facilitated. 

Goodell and others place strong emphasis on the great ad- 
vantage of antero-posterior oscillatory movements to be given 
the foetal body while traction is being put upon the legs. By 
virtue of it, a powerful leverage is obtained, which must afford 




Bl-PARIETAL- 



BMEMPORAL 



Fig. 233. — The transverse diameters of 
the Head as viewed from above. 



Parturient Anomalies. 497 

decided aid in getting the head past the narrow strait. It is 
mainly by virtue of this that the extensive molding of the head 
represented in figure 234 is effected. 

Nor should we in this connection forget that in some forms of 
pelvic contraction, one lateral half of the brim is more capa- 
cious than the other, in which case it may be possible to turn 
the occiput, in head-first cases, to that side, or, failing in such 
attempts, we may, by performing version, secure a favorable 
adjustment of the part to the anomalous outline of the brim. 

In transverse presentation, version by the feet should be un- 
dertaken, whether there appears to be any possibility of saving 
the child's life or not, and if extraction cannot be accomplished, 
the after-coming head can be perforated. 

Traction Force Applied After Version, with Eesults. — 
Charpentier de Ribes conducted some careful experiments with 
a view to determine the degree of traction force required in 
difficult cases of delivery through contracted pelves, after ver- 
sion. Fifteen times out of thirty-four, the head, at term, was 
brought through pelves measuring 2.9 inches by the use of a 
force varying from 45 to 66 pounds. In a pelvis of 2.6 inches, 
5 times the head was extracted by a force of 66 to 121 pounds, 
and 6 times it could not be moved, although a force of 176 
pounds was applied. Before term the maximum force used was 
55 pounds. As for the lesions, in all the cases before term ex- 
cept one, the parietals were fractured; at term, the same, 
whenever the traction force exceeded 89 pounds. The maxillary 
bones were fractured in the foetus at term whenever the force 
exceeded 55 pounds ; before term when it exceeded 46 pounds. 
Lesions of the vertebral column, before term, at 88 pounds, at 
term 110 pounds. As elsewhere stated, Goodell says he has 
delivered a living child in this manner under a traction force of 
100 pounds. 

The Forceps and Version Compared.— Instead of entering 
into a recitation of the various arguments advanced by the 
advocates of these operations, we give a brief comparison of 
the operations themselves. 

It is understood that passage of the head constitutes the 
principal difficulty. Now on the manikin it is clearly demon- 
strable, that, in equal degrees of contraction, it is incontes- 
tibly easier to effect delivery of that part by version than with 
the forceps. 

It is quite true also in a living woman, with a dead foetus, 

(32) 



498 Labor. 

that movements can be given the child, favorable to delivery, 
which the forceps will not permit. But in a living woman, with 
a living child, the case is different in a practical sense, and the 
chief element of distinction, and the one demanding special con- 
sideration, is found in the fact of foetal life. 

On the side of the forceps it may be said that traction can 
be applied with comparative safety for a period of at least a 
half-hour, while in the instance of version, delivery of the head, 
after this part engages the pelvic brim, cannot exceed five 
minutes with any degree of safety. 

In using the forceps there is not only no demand for a hasty 
delivery, but we feel constrained to consume some time in order 
to protect the soft maternal tissues, and we can do so with the 

utmost safety to foetal 
life. But in case of version 
there is urgent necessity 
for rapid delivery in the 
child's interest, and at 
some risk to the mother. 
While version, then, af- 
fords greater facility for 
foetal delivery, it measur- 
Fig. 234.— Molding of the Head at the ably augments foetal mor- 
brim in difficult cases of extraction after talitv. 

ersion ' These considerations 

should all enter into our judgment of the proper procedure 
in individual cases. 

We conclude that version is preferable in all other presenta- 
tions than that of the vertex, and is the procedure to adopt in 
those cases of the vertex which seem to offer some encourage- 
ment for the forceps, but wherein the forceps fail to effect 
delivery, unless further examination disclose the utter impossi- 
bility of extraction without perforation. 

The forceps are preferable when pelvic contraction is not be- 
low three and a quarter inches, and the head appears to be of 
standard size ; when the cord has not prolapsed ; and when no 
serious impediment to perfect application of the forceps exists. 

Following was the result of Scanzoni's experience in these 
cases : 

Forceps. Version. 

Mothers saved 94.7 85.7 

Infants " , 65.8 31. 




Parturient Anomalies. 499 

When the natural efforts are sufficient, after due molding of 
the head, to force it into the pelvic cavity, further progress may 
be obstructed, or the pains may become weak, either condition 
bringing into requisition the forceps. 

It is manifest that perforation will be required when, after 
version, we are unable to deliver the head, or when, in un- 
changed presentations, the head cannot be delivered from the 
brim, the cavity, or the outlet, by means of the forceps. 

Cases in which a Full-term Living Child Cannot be Born, 
but Delivery Through the Natural Passages is Advisable. 
— We have at our command in this class of cases but two 
operations, namely, craniotomy, and the induction of prema- 
ture labor. The latter, of course, cannot be performed except 
in those cases wherein the condition of the pelvis is recognized 
for some time before the close of utero-gestation, and, hence, is 
limited to only a certain proportion of the cases which we are 
called to treat. 

The question of inducing premature labor has been considered 
earlier in this chapter and does not require farther mention. 
Accordingly we shall discuss the treatment of such cases only 
as have gone to the close of normal pregnancy. "If labor 
comes on at full term," says Lusk, "before craniotomy is pro- 
ceeded to, an attempt should be made to gauge the degree of 
disproportion between the head and the pelvic brim, for not 
only is it among the bare possibilities that a living child may 
be expelled through a pelvis measuring less than three inches, 
but it is to be borne in mind that in pelvic mensuration even 
the most expert may make errors of a quarter of an inch." 
* * * " Craniotomy should not be performed so long as the 
hope exists of saving the life of the child." An approximate 
estimate of the size of the head can be made by palpation of 
the hypogastrium, conjoined with the vaginal touch. We may 
learn still more by passing the half-hand into the vagina, which 
procedure, in such cases, is perfectly justifiable. 

Cases Wherein Extraction Through the Natural Pas- 
sages Appears to be Impossible. — In cases of extreme pelvic 
contraction, the natural forces are incapable of effecting de- 
livery, and art offers but little hope either to mother or child. 

When the degree of pelvic contraction is known in the early 
months of pregnancy, we are perfectly justifiable in producing 
an abortion. If left till a late period in gestation, the only opera- 
tions open to our election are those necessitating laparotomy. 



■ny 



500 Labor. 

We should not omit to say, however, that in a few instances, 
craniotomy has been successfully performed in pelves with a 
conjugate of only one and a half inches. Dr. Parry collected 
seventy cases of craniotomy in pelves measuring two and one 
half inches, or under, but seven of them had finally to be termi- 
nated by Caesarean section. Out of the whole number, 
forty-three survived. Notwithstanding these comparatively 
favorable results, we believe that the operator of limited 
experience and skill will be more likely to obtain favorable re- 
sults from the improved Csesarean section, or a modification of 
Porro's operation, in such cases, than from craniotomy. 

Still we should make a distinction between cases by taking 
into account the transverse measurement, since craniotomy can 
be performed with much greater ease and safety in pelves with 
an ample transverse diameter, than in those equably con- 
tracted. 



Parturient Anomalies. 501 



CHAPTER XIII. 

PARTURIENT ANOMALIES REFERABLE TO THE FCETUS, OR ITS 

APPENDAGES. 

Plural Pregnancy.— " In general," says Blundell, "as we all 
know, women present us with a single child only ; sometimes, 
however, they favor us with two, three, four or five at a birth, 
and their generous fecundity may even exceed this number. 
Sennert relates the case of a lady who produced at once as 
many as nine children, nor does this appear to be wholly incredi- 
ble ; and Ambrose Pare tells us of another lady, a co-rival of 
the former, I presume, who gave to our species no fewer than 
twenty children,— I do not say at a single birth, but in two 
confinements." 

Twins are produced once in ninety or one hundred cases; 
triplets once in seven thousand, and quadruplets once in many 
thousands. There are but a comparatively few instances on 
record of five children at a single birth. 

The sex of twins is divided, i. e., one boy and one girl in 
about one-third of all cases. Both fcetuses are boys in about 
thirty-five per cent, of cases, and girls in about thirty per cent. 

Pathological specimens show that twin pregnancy may 
result from impregnation of two ova from the same or different 
Graafian follicles, or may originate from a single, ovum with 
double vitellus. The ova may not only come from distinct 
follicles, but also from different ovaries. Then, too, it is quite 
probable that by super-fecundation, or even by super-fcetation, 
twin pregnancy may be produced. 

Super-fecundation and super-fcetation are defined by Scan- 
zoni ; the former being where a second impregnation succeeds 
the first after an interval of varying duration, but before for- 
mation of the decidua reflexa about the first ovum; and the 
latter where a second impregnation takes place after the first 
ovum becomes completely inclosed by that membrane. 

Arrangement of the Membranes in Plural Pregnancy. 
—When twins are developed from two ova, each foetus has its 
own chorion and amnion, but the two may have a common 
decidua, and the placentae be united by their borders. If the 
points of original implantation be widely separate, the decidua 
reflexa and the placenta of each may be distinct. When the 



502 



Labor. 



development is from a single ovum, the placentae may be fused 
into one mass, or there will be but a single organ with a 
bifurcated cord. The decidua and chorion are common to 
both, and in some cases the amnion as well. Twins from the 
same ovum are always of the same sex. In triplets it is com- 
mon to find one child derived from an independent ovum, and 
two from a single one. 

Conditions Attending Intra-uterine Development. — 
Twins at birth often present appearances differing greatly as to 




Fig. 235.— Twins lying laterally, Fig. 236— Twins, one anteriorly 

one presenting by the vertex and and the other posteriorly. (Budin.) 
the other by the breech. (Budin.) 

size and conformation. In other cases earl}- death of one em- 
bryo takes place, but the dead and the living remain together 
till the full period of ufcero-gestation has been completed. As 
stated in another chapter, the dead foetus is sometimes expelled, 
and without disturbing the uterine relations of its mate. Very 
rarely when both children are living, but when their rate of de- 
velopment has been different, the one which first reaches ma- 
turity is expelled, and the other is retained until its development 



Parturient Anomalies. 



503 



has become complete. Just what bearing these facts have 
upon the question of super-foetation or super-fecundation we 
will leave for others to show. 

Labor in Plural Pregnancy.— The expulsion of the first 
foetus is usually more tardy and difficult, because the second 
child makes every uterine effort awkward and unusually labo- 
rious. When the first child presents by the breech, the os uteri 
expands more slowly because the presenting part cannot be 
driven down with ordinary force against the lower uterine seg- 




Fig. 237. — Twins, the inferior 
presenting by the breech, and the 
superior by the shoulder. (Budin.) 



Fig. 238. — Twins, the inferior 
presenting by the dorsum, and the 
superior by the vertex. (Budin.) 



ment, and descent of the trunk through the pelvic canal is slow 
for the same reason. Especial difficulty is met when birth of 
the trunk has been partially accomplished, since neither the 
contracting uterus nor the accoucheur's hand can press to ad- 
vantage upon the retained head to aid delivery at the momeut 
of greatest need. 

Management of the First Birth.— But few special direc- 
tions are required for management of the first birth. The cord 
should be tied in two places and severed between the ligatures, 



504 



Labor. 



as is commonly done in single births. We have then to await 
renewal of uterine action, when descent and expulsion of the 
second child should be managed much like a case of single 
birth. 

Delay After Birth of First Child.— In general, there is a 
brief interval of rest between the expulsion of the first child 
and renewal of uterine action for the expulsion of the second. 
Ordinarily, this interval does not extend beyond a period of 

fifteen or twenty min- 
utes, but in some cases, 
hours, or even days, 
intervene. For cases 
wherein there is un- 
usual delay, the plan of 
treatment has not yet 
become uniform in 
either theory or prac- 
tice. Some regard any 
interference whatever, 
having for its object 
delivery of the second 
child, as "meddlesome 
midwifery/' and to be 
discountenanced. Oth- 
ers recommend the 
medical attendant, 
after the usual delay of 
fifteen or twenty min- 
utes, to rupture the 
membranes of the sec- 
ond child, if the presen- 
tation is natural, and 
stimulate the uterus to renewed activity. Later, if necessary 
to expedite delivery, instrumental aid is advised. 

In case of transverse presentation, or of face presentation 
wherein rectification is deemed advisable, it is agreed that the 
necessary operation should be performed without unnecessary 
delay. 

If the presentation is either pelvic or vertex, the attendant 
need not go to either extreme, but give the uterus a reasonable 
time during which to recuperate its energies, so that, if spon- 
taneous action does not ensue, the powers of the organ may be 




Fig. 239. — Twins, both lying transversely, one 
above, the other below. (Budin.) 



Parturient Anomalies. 



505 



aroused by suitable stimulation. If the membranes are un- 
ruptured, they may be broken after an interval of say an hour, 
when the case should be left to nature in the expectation that 
delivery will soon be undertaken. 

Among the remedies suitable to the case at such a juncture 
of affairs, are those given under the head of uterine inertia. 

Slight stimulation of the womb by careful manipulation of 
the cervix and kneading of the abdomen is permissible. If, de- 
spite these measures, expulsive action is not set up, the forceps 
may be applied, and delivery carefully effected under the strict 
precautions mentioned in the observations on treatment of 
uterine inertia. Ver- 
sion is preferred by 
some, inasmuch as 
the parts have been 
so well dilated by 
the passage of the 
first child that the 
requisites for suc- 
cessful delivery are 
well met. If the sec- 
ond child present by 
the breech, and there 
appear to be any 
necessity for urging 
the delivery, the us- 
ual management of 
such cases may be 
ignored and the feet 
brought down. 

Exceptions to this plan of treatment arise under the follow- 
ing circumstances: 1. When the first foetus and membranes 
have been fully delivered ; and 2, when the foetuses are known to 
be immature. 

In the first instance we have no means of knowing with 
certainty whether the second foetus is fully mature, and if not, 
its best interests will be subserved, and the mother's interests 
will not be prejudiced, by allowing it to remain undisturbed. 
In the second instance, knowing the foetus to be immature, we 
are fully justified in making a certain degree of effort to bring 
away the membranes of the first foetus, with a view to leaving 
the second foetus behind for farther development. 




Fig. 240.— Head-locking. (Barnes.) 



506 



Labor. 



Locked Twins.— The presence of a second foetus sometimes 
seriously complicates delivery. When both children present by 
the vertex, both heads sometimes attempt to enter the brim at 
the same time, and in this way farther progress becomes im- 
peded. When the pelvis is capacious, or the heads are unusually 
small, both heads may even get into the pelvic cavity. Eei- 
mann mentions such a case, wherein he effected delivery, first 
of one head and then the other, the foetal trunks following in 
similar order. 

When both heads are discovered at the brim, the higher one 




Fig. 241.— Head-locking. (Barnes.) 



should be pushed away by means of combined manipulation, 
and the lower one permitted to descend into the strait. 

When one foetus presents by the head and the other by the 
breech, a more common, and no less serious, complication is 
liable to arise, in one case within, and, in another, above the 
pelvis. 

When the heads lock within the pelvic cavity, the second foetus 
can occasionally be drawn down past the first, and the tangle 
thus be undone. Failing in such an attempt, the upper head 
may be perforated and delivered, or it can be decapitated and 
left in utero until after delivery of the other foetus. 

When the heads lock above the pelvis, success by manipula- 



Parturient Anomalies. 



507 



tion is not impossible, but if it fail, decapitation of the head of 
that foetus which presents will be necessitated. 

Double Monsters.— When the bodies of two foetuses are 
partially fused together, the management of delivery becomes 
a most responsible and difficult undertaking. Nature is gener- 
ally equal to the emergency, as will be seen when we state that 




Fig. 242.— Double Monster, 

out of thirty-one collected cases, twenty were spontaneously 
and easily terminated. Such results are partially explained by 
the fact that in quite a percentage of all these cases labor is 
premature, while in others the foetuses are dead and somewhat 
decomposed. 

The Mechanism of Delivery.— The mechanism of delivery will 



508 Labor. 

vary according to the character of the anomaly, but the chief 
difficulty is usually in the delivery of the heads. In head-last 
cases it is of prime importance to carry the bodies well for 
ward over the maternal abdomen, in rational attempts at 
delivery, so that one head may enter in advance of the other 
In head-first cases, expulsion is commonly effected by the 




Fig. 243. — Double Monster united anteriorly. 

bodies performing a movement somewhat like that of spon- 
taneous evolution in transverse presentation. The head and 
body of one foetus passes, followed by the pelvis of the second 
in advance of the head. 

When delivery of living children is impossible, the body of 
one must be mutilated to make room for the escape of the 
other. 



Parturient Anomalies. 509 

The result to the mothers does not appear to be so disas- 
trous as might be expected. Their dangers, however, are con- 
siderably augmented. 

Intra-uterine Hydrocephalus.— Under this title we mean 
to include all the dropsies of the head, and all the extensive 
effusions or infiltrations of serum within or without the cra- 
nium; but inasmuch as external hydrocephalus is rarely of 
sufficient extent to constitute an obstacle to delivery, we shall 
confine our observations chiefly to the internal variety. 

Hydrocephalus intern us is a foetal disease which com- 
plicates labor once in 3,000 births. In 43,555 labors, Madame 
Lachapelle observed but fifteen cases. 

The causes are not well known, but among them we may 
mention alcoholism, syphilis, cretinism and consanguinity. 

The redundant fluid may be found in four different loca- 
tions, namely : (1) in the space between the duramater and the 
skull; (2) in the arachnoid cavity; (3) in the space beneath 
the arachnoid ; and (4) in the cerebral ventricles. 

It must be regarded as a serious complication of labor. 
Parturition is sometimes easy, sometimes difficult and some- 
times impossible. 

In seventy-four cases collected by Dr. Thomas Keith, 
uterine rupture occurred sixteen times. 

Spiegelberg collected ninety-four cases with twenty-four 
deaths, and Poullet one hundred and six cases with twenty-one 
deaths. 

Nor is this the only danger to which the woman is exposed. 
The head, when excessively developed, constitutes an insuperable 
obstacle to delivery, the uterus after a time becomes exhausted, 
and there supervene the dangers attendant on uterine inertia, 
not least among which, in neglected cases, is that of long- 
continued compression of the soft pelvic structures. 

Diagnosis. — Playfair says that ''the diagnosis of intra- 
uterine hydrocephalus is D3 r no means so easy as the descrip- 
tion in obstetric works would lead us to believe." * * * "As 
a matter of fact, the true nature of the case is comparatively 
rarely discovered before delivery ; thus Chaussier found that in 
more than one-half of the cases he collected, an erroneous 
diagnosis had been made." 

Whenever the labor is difficult, without other apparent cause 
than the size of the foetal head, our suspicions should be 
aroused. These will be strengthened by separation of the pari- 



510 Labor. 

etal bones at the sagittal suture. A positive diagnosis cannot 
be made without introducing the hand into the vagina, and the 
fingers into the womb ; hence it should be regarded as not only 
the privilege, but the duty, of the physician, in suspected cases, 
—in fact in any case where the diagnosis cannot otherwise be 
clearly established, — thus to act. 

"The unusual size and dimensions of the head might be thus 
ascertained," says Simpson, "but one source of fallacy is to be 
guarded against, namely, that the sutures and fontanelles are 
not, as was usually described, always preternaturally open and 
enlarged in hydrocephalic cases ; for the cranial bones are in 
some instances, where the internal effusion is great, so largely 
and abnormally developed as to destroy this supposed pathog- 
nomonic sign, and to form an almost complete osseous covering 
for the enlarged head." 

In most cases the cranium presents a fluctuating feel, so 
marked in some instances as in a degree to resemble the bag of 
waters, but communicating to the examining finger the hairy 
and thicker feel of the scalp. Still a hydrocephalic head has 
been perforated under the impression that it was the foetal sac 
with unusually thick walls. 

Presentation, etc. — Other than head presentations are ex- 
ceedingly common in connection with hydrocephalus. Out of 
152 cases collected by Scanzoni, 30 presented by some other 
part than the head. Poullet in 106 cases found only 65 vertex 
presentations. 

When the pelvic extremity presents, the difficulties of the case 
are not likely to be realized until the trunk has passed the 
vulva and the head descends to the superior strait. Even then, 
though the character of the complication will probably be rec- 
ognized, the precise cranial dimensions cannot be determined. 
The finger cannot reach far enough to make a thorough explora- 
tion, and examination through the abdominal walls is not 
at all satisfactory. However, if by conjoint manipulation,— 
one hand on the abdomen and the fingers of the other in the 
vagina. — the remarkable size of the head is made out, and 
further, if the body of the foetus presents the shriveled appear- 
ance so generally observed in connection with intra-uterine 
hydrocephalus, diagnosis may be made with some degree of 
confidence. 

Treatment. — In those fortunate instances of easy labor and 
vertex presentation in connection with hydrocephalus, no 



Parturient Anomalies. 



511 



special rules for management need be given. If much difficulty 
is experienced by the head in passing through the pelvis, the 
forceps will often afford efficient aid. When the cranial dimen- 
sions are too great to respond to such attempts at delivery, 
aspiration must be performed, or the cranial fluid drawn off 
with a trocar. After thus reducing the head, the forceps can- 
not be easily made to hold with sufficient firmness to effect 




Pig. 244.— Pelvic presentation with Hydrocephalus. (Herrgott.) Tapping 

through spinal canal. 

delivery. In case of failure with the forceps, the cephalotribe 
may be applied, or version may be performed. 

When the pelvic extremity presents, and delivery of the 
after-coming head cannot be effected, perforation should be 
performed behind the ear,— a thing, by the way, not always 
easily done. Or we may resort to Van Huevef s procedure, 



^H^^H^M^H 



512 



Labor. 



which consists in transverse section of the spinal column, 
opening the rachidian canal and through that drawing off the 
cranial fluid if it chance to be in relation therewith. When 
the fluid is not in the ventricles, a sound may be passed along 
the vertebral canal to the site of the accumulation within the 
cranium. 

Hydrothorax — This is a rare complication of delivery. It 
is indicated by enlargement of the thorax, widening of the 
intercostal spaces, and fluctuation therein. If distension is great 

enough to prevent delivery, 
paracentesis thoracis must be 
performed. 

Ascites, and Vesical Dis 
tension. — Ascites is more fre- 
quent than hydrothorax. It 
gives rise to abdominal disten- 
sion and fluctuation. Descent 
is accomplished, and a part of 
the trunk is expelled, when 
labor is arrested by the pres- 
ence of a large, soft, fluctuat- 
ing tumor which proves to be 
the distended abdomen. Tap- 
ping with an aspirator needle 
is the form of treatment to be 
adopted. 

Vesical distension can rarely 
be differentiated from ascites in 
an undelivered foetus. If the 
pelvic extremity is the present- 
ing part, it may be found prac- 
ticable to pass a small rubber catheter, and thus distinguish 
the one condition from the other. 

Other Abnormalities of the Foetus.— Fcetal tumors of 
various parts, such as spinabifida, hydroencephalocele, or hydro- 
rachitis, as well as tumors of the liver, spleen and kidneys, may 
obstruct labor, but they are rarely large enough to do so. 
When their contents are fluid, they should be drawn off, if nec- 
essary ; and, in the case of solid growths, evisceration may be 
required. 

Other deformities of the foetus, such as those presented by 
the anencephalus, acephalus and acrania, as well as those 




Fig. 245.— Mode of perforating the 
Head in pelvic presentations. 



Parturient Anomalies. 



513 



having defective thoracic and abdominal development, with 
protrusion of the viscera, are rarely capable of proving ob- 
structive to labor, but their anomalous features may render 
diagnosis difficult, and often impossible. 

Large Fcetuses. — While the average weight of the foetus at 
birth is about seven and a half pounds, this is often consider- 
ably exceeded. What adds to the difficulties of labor in such 
cases is the strong tendency of large children to unusual cranial 
firmness and ossification. 

When the head is too large to enter the pelvic brim with its 
usual facility, the same general principles 
must control the treatment which are 
set forth in connection with pelvic con- 
traction. The forceps will usually,— we 
may say, nearly always, — be adequate 
to the emergency. In rare cases perfo- 
ration will be required. 

When the trunk of the child is un- 
usually large, delay is most commonly 
occasioned by the shoulders. When the 
head has passed the vulva and much 
time is lost in getting away the shoul- 
ders, fcetal dangers are greatly aug- 
mented. If the child is already dead, 
there does not exist the same urgent 
demand, and more deliberation is called 
for. In a few recorded cases it has been 
found utterly impossible to extract the 
trunk without evisceration. 

A woman was recently confined by 
the author with her fourth child. The three former children 
were all still-born, and her medical attendant, a man of skill 
and experience, informed her that the cause of the stillness 
was in each case long retention of the trunk after cephalic ex- 
pulsion. In the fourth labor a like complication arose, and 
only with the greatest difficulty were the shoulders extracted in 
time to save the life of the child, which for a time seemed lost 
through asphyxia. 

Treatment.— Efforts at shoulder extraction in such cases 

are made under most unfavorable conditions. The pelvic 

outlet is usually so well filled that the fingers cannot reach the 

axilla?, while traction on the head is a dangerous procedure. 

(33) 




Fig. 246.— Dorsal dis- 
placement of the Arm. 



514 Labor. 

The first efforts should be to stimulate uterine contraction by 
abdominal friction, and slight traction on the foetal head. 
These are usually sufficient. Should they fail, stronger traction 
may be made on the head, but not to exceed a few pounds, 
while forcible abdominal pressure should be exerted by an as- 
sistant. These combined endeavors will nearly always be 
crowned with success. We should not omit to say, however, 
that rotation of the bis-acromial diameter into the conjugate 
of the outlet is here almost a necessity, and it may be favored 
at first by rotary pressure of the fingers upon the shoulders, 
and subsequently by suitable traction with the fingers in the 
axillae. The blunt hook is here sometimes serviceable as a 
tractor. 

Dorsal Displacement of the Arm.— In these really diffi- 
cult cases the arm is applied to the side of the head so that its 
bulk is added to the biparietal diameter, while the forearm is 
flexed at the elbow and the hand lies behind the occiput. 

It is to be treated by hooking the fingers into the bend of 
the elbow, and pushing the arm forward until it is finally made 
to sweep over the chest. 



Parturient Anomalies. 515 



CHAPTER XIV. 

PARTURIENT ANOMALIES REFERABLE TO THE FCETUS OR ITS 
APPEND A GES— Continued. 

Unavoidable Hemorrhage,— Placenta Prsevia.— In order 
that one may obtain a clear conception of what is signified by 
the term "unavoidable hemorrhage," it is essential that he 
have a lucid idea of the anatomy, physiology and pathology of 
placenta prsevia. 

In pregnancy as it ordinarily exists, the fecundated ovum 
upon entering the uterine cavity lodges upon one of the shelves 
formed by the tumefied and rugose mucous membrane, in the 
superior portion of the uterine cavity, and at this point forms 
its attachments. Development here proceeds to full maturity, 
and as the os uteri expands in parturition, and the foetus de- 
scends, the placenta, because of its favorable situation, suffers 
no necessary separation until after expulsion of the child, and 
the consequent termination of its functional activity. In other 
cases, happily few in number, the formative processes pursue an 
anomalous course, ultimating in great suffering and peril. The 
little egg, heavy with possibilities, eludes the prehensile forces 
of the superior portion of the uterine cavity, and sinks by its 
own weight to a lower point, where it lodges and soon contracts 
its placental relations. As foetal supplies are all carried through 
the utero-placental circulation, a considerable basis of supply 
is established on the lower segment of the uterus, as a result of 
which the proportions of the part are augmented, and the walls 
thickened: small vessels becoming blood sinuses. The presenting 
vertex of the foetus rests down on the placenta which is spread 
upon this part, and, when labor begins, with expansion of the 
os uteri there is more or less disruption of vascular relations. 

The placenta, an organ of the utmost vascularity, occupies 
the lower uterine segment, covering the internal os uteri, and, 
as the maternal sinuses have been formed over and about the 
closed os, the very commencement of dilatation must begin the 
process of placental separation. As foetal expulsion cannot 
occur without dilatation of the os uteri, and as the os uteri 
cannot expand without rupturing blood-vessels, there is set up 
a hemorrhage which is very appropriately termed " anavoid- 
able." 



516 



Labor. 



Varieties. — The placenta, as a rule, is not situated precisely 
over the center of the lower segment of the uterus, but more or 
less to one side, — on the right, or the left, anteriorly or pos- 
teriorly. The nomenclature of placenta prsevia correspondingly 
varies. Thus we have 1. Lateral placenta; 2. Latero-cervical 
placenta; and 3. Cervico-orifical, or central placenta. 

For practical purposes we may make but two classes, the 
first being termed partial, marginal or incomplete placenta 
previa, and the second, total, central or complete. 

Frequency.— Placenta praevia 
is a complication of pregnancy 
and parturition encountered but 
once in about five hundred cases. 

/ M Causes of the Hemorrhage. 

y 

; |jjA — The causes which are proposed 

J; ; 1*\ to account for the excessive 

1 iii'! 1 ! | || hemorrhage in connection with 

.\ If] placenta prsevia have been mat- 

fl Iff ters of considerable dispute. 

§L f§k The earlier, and usually light, 

^ C /4Jf l° sses which are in most cases 

mjr§ suffered, have been regarded by 

W^$M some as accidental. This may be 

fj| true in a small percentage of 

P-fl * cases, but it can hardly be ac- 

JfJ credited concerning the phenom- 

0jp^u en on in general. The immediate 

p /| causes of the bleeding which un- 

"*" 4 avoidably takes place in placenta 
Fig. 247— Varieties of Pla- . J , *\ , \. ,, . 

,.-,*.., *. ™ ^ f a„i prsevia were shadowed forth in 

cental Attachments. E E, f undal * 

placenta. D D, lateral placenta, the introductory observations, 

F F C B, latero-cervical placenta, but here we may give them in de- 

AB BF, seat of cervico-orifical, ta ji j t j s sa j^ that, during the 

or central placenta. firgt fiye months of utero-gesta- 

tion, developmental energy is exerted more especially in the 
superior portion of the womb, during which period the cervical 
region is but slightly modified. Subsequently there is a change, 
we are told, and very soon the cervical canal is encroached 
upon by the capitulation of the internal os, so that for a con- 
siderable time before labor the os externum alone is left for 
future dilatation. In support of this theory, progressive short- 
ening of the cervix uteri is cited. Hence, they say, as soon as 




Parturient Anomalies. 517 

the cervical canal begins to expand by reason of the submission 
of the os internum, small arterial twigs in the utero-placental 
vascular system are apt to break, and cause hemorrhage 
which is soon arrested by the formation of coagula. This may 
repeatedly occur. 

We have elsewhere taken occasion to express our want of 
concurrence in the theory upon which this explanation rests. 
We are convinced, from attentive observation of the phenomena 
involved, that cervical shortening is more apparent than real, 
and that the internal os uteri commonly preserves its contrac- 
tion until near the beginning of labor. Hemorrhage in these 
cases may be due to the increased strain put upon the lower 
uterine segment after the sixth month of pregnancy, the uterine 
walls yielding to the force more rapidly than the utero-placental 
vessels, and thus giving rise to rupture of arterial twigs, or 
capillaries. It may also be true that in placenta previa the 
anomalous development going on about the internal os makes 
it more patulous than in other cases. 

But there comes a time when, through rhythmical uterine 
contractions, the cervical canal becomes at first funnel-shaped, 
and afterwards wholly expanded, so that the external os is left 
as the last part to yield. As expansion begins, blood gushes 
forth from ruptured vessels, but whether the hemorrhage is 
from the uterine or the placental side is still a question. It may 
come from both. The weight of opinion appears to be that the 
blood issues mainly from the uterine surface, though it cannot 
be denied that strong evidence has been adduced in favor of 
the opposite view. 

Symptoms.— The patient may be asleep, or she may be occu- 
pied in the performance of her household duties, when suddenly 
blood bursts from the uterus, soon followed, perhaps, by faint- 
ing, and sometimes, though rarely, by death itself. 

In some women an occasional flow occurs for a number of 
weeks before the onset of labor. It comes profusely for a few 
moments, and then disappears, so that aid is not often secured 
in time to be of immediate service. The final hemorrhage sets 
in in like manner, and continues with uneven progress until 
arrested by well directed treatment, or brought to a close 
through utter exhaustion. In other cases there is no warning 
whatever. Gestation pursues an uneventful course, and, with 
animation and hope, the woman contemplates the near ap- 
proach of the time when the restraints of pregnancy shall be 



518 Labor. 

removed, and the trials and pains incident to its termination 
shall be succeeded by the tender delights of maternity, when 
suddenly she finds herself in the very valley of the shadow of 
death. There is a gush of fluid, which, on inspection, is found 
to be blood, and it pours forth in a sickening stream. If it con- 
tinues, respiration becomes sighing, the pulse rapid, feeble, and 
finally absent, the countenance pallid and the extremities un- 
easy; syncope supervenes, and too frequently death ends the 
scene. The torrent may spontaneously cease for a time ere 
these extreme symptoms are developed, and the worst seem to 
have passed, when a renewal of the flow ensues and Death 
claims his victim. 

For a time the uterus may act with its wonted energy, but 
excessive depletion is apt soon to paralyze its efforts. Occasion- 
ally labor hastens on its course, and, if favored by a passive and 
sparing flow, soon reaches a stage in which efficient pressure is 
laid on the bleeding surfaces, and the pernicious bleeding is 
brought to a close. In other cases, after the loss of a great 
quantity of blood the flow spontaneously ceases, not to return, 
and labor thenceforth takes a normal course, unless complicated 
by great weakness. 

These are exceptional cases, for when the tide of vital fluid is 
not held in check by artificial means, or the conditions on which 
it depends are not rectified by judicious treatment, the foun- 
tains of life soon run dry. 

Through energetic uterine action, in rare cases the placenta 
is separated and driven down into the vagina in advance of 
the foetus. When this takes place before depletion has become 
too excessive, the outcome is usually favorable. 

When the case is of the incomplete variety, there is some- 
times but a moderate flow at the most, and even that is soon 
subdued by either natural or artificial means, and serious dan- 
ger thereby averted. This result is explained by the slight 
extent of necessary separation, and the early descent of the 
presenting part into the pelvic inlet. 

Post-partum hemorrhage is relatively frequent in these cases, 
growing out of inability of the lower part of the uterus to con- 
tract with sufficient force and persistency to control the bleed- 
ing vessels. 

Diagnosis. — However small a figure may be cut by diagnosis 
in certain diseased stales and obstetric conditions, it is here of 
surpassing importance. The perils of the emergency, and the 



Parturient Anomalies. 



519 



possibilities of treatment are too great to tolerate anything 
less than most careful and thorough search for the conditions 
upon which hemorrhage before delivery depends. 

The differentiation between accidental and unavoidable hem- 
orrhage will be considered when we come to discuss the former 
complication of pregnancy, but we may also here glance at 
some of the roou valuable diagnostic points. 




Fig. 248. — Central Placenta Previa. 

As soon as the hemorrhage is gotten under control, we 
should investigate the history of the case, and learn whether 
there have been previous hemorrhages, under what circum- 
stances the flow began, the possible influence of accident in 
developing it, and the position of the body at the moment when 
it set in. But it is only after a thorough vaginal examination 
that a positive diagnosis can be reached. The os will generally 
admit the finger, though it be not dilated, because of its 



520 Labor. 

dilatability, a condition brought about mainly by the blood- 
loss. If the finger can be passed, we shall almost always be 
able to feel some portion of the placenta. If the implantation is 
central, we find the cervical canal covered by a thick, boggy 
mass, readily distinguishable from any part of the foetus, 
and from a coagulum. Pressing upon this mass, we feel 
the resistance offered by the presenting part of the foetus. 
When but a part of the placenta lies over the os, its spongy 
tissue will be distinctly felt, and, through the membranes at- 
tached to it, the foetus will be clearly made out. On account of 
a high situation of the uterus we may not be able to make a 
satisfactory examination of the os and cervix without introduc- 
ing the hand. There is a sensation of thickness and vascularity 
about the lower uterine segment not observed in normal preg- 
nancy. Furthermore, the relation, in point of time, between 
the crimson gush and uterine contraction, should be attentively 
observed, since their simultaneous occurrence characterizes 
unavoidable, and not accidental, hemorrhage. 

Prognosis. — According to the calculation of Sir James Simp- 
son, based on an analysis of 399 cases, one-third of the mothers, 
and over one-half of the children, were lost. Out of sixty -four 
cases recorded by Barnes, the maternal deaths were 6, or 1 in 
10%. Eead estimates the maternal mortality at 1 in 4% 
cases. 

The adoption of Braxton Hicks' method of version in the 
management of these cases, and the use of antiseptic precau- 
tions, have greatly reduced maternal mortality. Homeopathic 
statistics show a foetal death-rate of 35.55. 

During the five years ending with 1887 there occurred in 
Crede's Leipzic Clinic sixty-four cases of placenta prsevia. 
Eleven per cent, of the mothers, and 55 per cent, of the children, 
died. Version by the combined method of Braxton Hicks, and 
slow extraction, were practiced in forty-nine cases. Excluding 
one case, in which the woman's condition was hopeless when 
first seen, the maternal mortality was but 2.1 per cent., while in 
the remaining fifteen cases treated by other methods it amounted 
to 33% per cent. 

Lomer had twenty-eight cases, treated by Hicks' method, 
with only one death. Among 190 cases occurring in German 
practice, only nine were lost. 

Foetal mortality in placenta prsevia has not been much 
reduced. It is still above 50 per cent. 



Parturient Anomalies. 521 

"The question of safety in labors with unavoidable hemor- 
rhage," says Meigs, "is very much a question of time, — for if a 
woman with central implantation of the afterbirth could, as some 
have done, expel the child in one or two hours, she would not 
have time to die, inasmuch as the involution power of the womb 
would shrink the bleeding surface so speedily after the expul- 
sion as to put an end to the flooding at once, and so to all 
dangers and alarm. On the other hand, where the woman con- 
tinues in labor for four-and-twenty hours, she will probably die, 
either before or soon after its conclusion." 

Life is not always destroyed as the immediate result of 
blood-loss; but a system thus rendered anaemic is far more 
likely to take on septic infection, and bedside observation has 
taught that septicaemia in the presence of anaemia is nearly 
always fatal. 

The cause of the heavy foetal mortality is obvious when we 
reflect on the sources of foetal supply, and the entire or partial 
placental separation which occurs. 

Treatment. — Upon clearly establishing our diagnosis, we 
ought carefully to consider the possibilities and probabilities 
of the case, and lay out a plan of treatment. 

On reaching our patient we should first enforce the general 
rules of treatment for uterine hemorrhage ; that is to say, we 
should allay fear, clear the chamber of all unnecessary com- 
pany, and strictly enforce the horizontal position. If the 
advisable course of treatment is not at the moment clear, we 
may, if necessary, at once introduce a tampon to arrest the 
flow, though this is to be avoided if possible. Pressure upon 
the fundus uteri, which pushes the head firmly against the 
bleeding placenta, is sometimes of service as a temporary ex- 
pedient. 

The plan of treatment will depend somewhat on the period 
of pregnancy at which the bleeding occurs. If before the full 
term of gestation has been accomplished, the question of favor- 
ing foetal expulsion has to be decided. 

Following are the various methods of treatment for placenta 
praevia which have been proposed : 

1. Treatment before moderate dilatation of the os : 

Method of Guillemeau Accouchement force (1571). 

Method of Greenhalgh Induced labor (1865). 

Method of Leroux Tampon (1776). 

Method of Barnes Use of Barnes' bags (1862). 



522 Labor. 

Method of Puzos .Rupture of the membranes (1759). 

Method of Deventer Perforation of the placenta (1734). 

Method of Dubois Administration of ergot (1836). 

Method of Wigand .External cephalic version (1812). 

Method of Seyfert Vaginal injection (1852). 

Method of Cohen Rupture of the membranes after separation of 

the placenta (1855). 
Method of Barnes Partial separation of the placenta (1862). 

2. Treatment after moderate dilatation : 

Method of Simpson Total removal of the placenta (1844). 

Method of Bunsen Partial removal of the placenta (1839). 

Method of Kristeller Foetal expression (1865). 

Method of Braxton Hicks. .Podalic version by conjoint manipulation (1864). 

Extraction by the forceps. 

Extraction by the hand (either with or without version). 

We cannot enter into a detailed account of these various 
modes of treatment, but shall content ourselves with a con- 
sideration of the most valuable among them. 

Treatment Before Moderate Dilatation oftheOs.— The 
Question of Inducing Foetal Expulsion. — In 1865 Dr. Green- 
halgh, of London, recommended the induction of premature 
labor in placenta praevia, and though differing in their modes 
of procedure, obstetricians have come to accept it for some cases 
as a wise form of treatment. Erect as we may the strongest 
safeguards, yet the woman in whom the placenta presents is 
constantly exposed to great peril. At any moment, in waking 
or in sleeping hours, the torrent may gush forth, and the vital 
forces be speedily reduced to their lowest ebb. With the best 
facilities for summoning aid, life is continually in jeopardy. 
But, by the induction of premature labor, the entire process of 
parturition is brought under the physician's personal super- 
vision, and the danger arising from hemorrhage accordingly 
reduced to a minimum. 

Over against these considerations should be set others of no 
little weight. Firstly, and chiefly, stands the augmented foetal 
danger which the operation involves. In response to this ob- 
jection it should be said, that, though we should not be justified 
in ignoring foetal claims, no conscientious protestant will deny 
that a fair and consistent view of their relative importance will 
always subordinate them to the maternal interests. In Amer- 
ica it appears to have become a rule of practice to make the 
mother's safety in every particular paramount to all other con- 
siderations. Nor should we forget that, while induction of 



Parturient Anomalies. 523 

premature labor is extremely hazardous to the foetus, its chances 
of living under the expectant plan is little greater than those 
of dying. The favorable results of treatment by induction of 
labor are shown by Dr. King. Oat of twenty-nine cases which 
came under his care before the days of antiseptic midwifery and 
the use of Hicks' method of version, there were twenty-three 
maternal recoveries, and eleven living children. 

"I think, therefore, "'* says Playfair, "that it may be safely 
laid down as an axiom, that no attempt should be made to 
prevent the termination of pregnancy, but that our treatment 
should rather contemplate its conclusion as soon as possible." 
We may make the single exception of diagnosis established be- 
fore the close of the seventh month, in which case we would be 
justified in temporizing until a little later period, on behalf of 
the child. 

Modes of Promoting Labor.— We have not here the same 
variety of means from which to choose that is offered under 
other circumstances, inasmuch as it is essential that, while we 
provide for the stimulation of uterine contractions and dilata- 
tion, we furnish an obstacle to the bleeding which is sure to fol- 
low. Instead of Kiwisclr s douche and other slow processes which 
afford no protection from hemorrhage, we are compelled to re- 
sort to other means. The finger should be used as a dilator 
from the very start, up to the time when a Barnes bagcanbein- 
troduced. But if the os uteri is very small, and the cervixis still 
hard in its upper portion, we begin by carefully introducing a 
tent, tamponing the vagina to hold it in place. As soon as this 
has accomplished its office, it should be withdrawn and super- 
seded by one of Barnes' bags. The bag is introduced in a 
flaccid state, and afterwards dilated with water, and left until 
it can be followed by another of larger size. If we are merely 
promoting labor already under way, we begin with the bags in- 
stead of the tent. Hydrostatic expansive force, thus applied, 
nicely simulates labor, and. when done under strict antiseptic 
precautions, the operation can hardly be regarded as imposing 
serious danger. By thus filling the os uteri, and following its 
expansion, hemorrhage is kept within bounds, and labor is 
rapidly promoted. 

As soon as dilatation has advanced to a certain point, arti- 
ficial extraction becomes possible. The precise degree of 
expansion required will depend on the state of the os with re- 
spect to dilatability and the mode of delivery proposed to be 



524 Labor. 

employed. The forceps can be used through an os uteri no 
larger than a silver dollar, and if the foetal head can be gotten 
at, this constitutes bhe preferable means. In other cases turning 
by Hicks' method should be practiced. 

Evacuation of the Liquor Amnii in the Management of 
Unavoidable Hemorrhage.— This expedient is by some regarded 
as almost uniformly efficacious ; but it is unsuitable if there is 
a probability of our being obliged finally to resort to podalic 
version. The favorable effects of rupture of the membranes 
arise from increased uterine condensation, and augmented 
pressure of the presenting part against the placenta and the 
ruptured uterine vessels. To these should be added the stimulus 
which is imparted to the uterus, and the consequent accelera- 
tion of the parturient process. 

This operation is best performed by means of a stiff catheter 
passed through the placenta, unless the membranes can be 
reached. Care should be taken not to wound the foetal head. 
The evacuation ought to be thorough, to accomplish which it 
may be necessary to leave the catheter within the amniotic sac 
for some minutes. 

When the liquor amnii is flowing away it will be observed 
that the stream ceases during a uterine contraction from the 
pressure exerted by the foetal head, which is driven down with 
force against the lower uterine sagment and the pelvic brim. 
It is a similar action, as we have said, upon which we rely in 
these cases to arrest the flow of blood. The effect may be 
maintained between the pains by pressure on the fundus 
with the palm of the hand, or even by means of a firm abdominal 
bandage. 

The Vaginal Tampon. — In the management of placenta 
prsevia the vaginal tampon has been a strong reliance in times 
past, until the os attains a size which admits of the practice 
of internal podalic version. But the danger of introducing septic 
matter, even under the strictest precautions, has been clearly 
shown, and Hicks has brought forward his improved method 
of podalic version, these two working a change in notions and 
practice which is rapidly discrediting the use of the tampon. In 
a recent paper Hicks strongly condemns it, and Wyder writes in 
a similar strain. The latter says that the tampon is uncertain 
in arresting hemorrhage, is often the carrier of infection, and 
that the use of it, followed by version, is a great loss of time. 
Version is his remedy par excellence. We may say for our- 



Parturient Anomalies. 525 

selves that in the several cases which have fallen under our 
care we have in only one instance had recourse to the tampon. 

Following' are the only indications for the tampon : Delay of 
the time when extraction, either manual or instrumental, can 
be practiced, with, meanwhile, a profuse flow of blood. Even 
then, however, w 7 e believe the use of Barnes' bags far preferable. 

The best materials for a tampon are antiseptic cotton, anti- 
septic wool and iodoform gauze. 

Thoroughly to pack the vagina the novice will find no easy 
task, and, if not thoroughly done, the operation is worse than 
useless. Before undertaking it the woman should be put into 
a favorable position across the bed, and the vulva thoroughly 
washed with an antiseptic solution. The vagina must also 
receive a douche. The perineum can be retracted either by the 
fingers, or a speculum, so as to admit the packing without 
serious irritation of the vulva and vagina. 

The following most effectual mode of applying the tampon 
was first recommended and practiced by Dr. Sims. "The pa- 
tient" (with empty rectum and bladder)," says Dr. Paul F. 
Munde, in his Minor Surgical Gynaecology, "occupies the left 
lateral prone position; Sims' speculum is introduced and the 
cervix exposed. All coagula and fluid blood having been care- 
fully removed by the dressing forceps and damp cotton, a disk- 
shaped tampon about two inches in diameter and one-half 
inch thick, is placed over the cervix. Another such tampon is 
rolled up and placed behind, another in front, and one on each 
side of cervix, and a large flat one over all these. These tam- 
pons are recommended by Emmet to be soaked in a saturated 
solution of alum and squeezed nearly dry. I always carbolize 
the tampons in a one per cent, solution, but think the alum so- 
lution a very good plan, as it contracts the vaginal pouah and 
thereby compresses the cervix. Occasionally it may be neces- 
sary to push a pledget of alum cotton into the cervical canal 
and thus arrest the hemorrhage until the whole tampon has 
been firmly placed. * * * The first circle and layer of tam- 
pons having been arranged, as described, and the vaginal 
vault thus filled and the cervix compressed in all directions, 
disk after disk of dampened carbolized cotton is laid around 
the circle of the vagina, filling up the center a/t the last, and 
each disk and each layer is gently but firmly pressed down and 
packed tight with the dressing forceps or a whalebone stick. This 
pressure should always be made from the periphery towards the 



526 



Labor. 



center, or rather from the anterior vaginal wall towards the 
sacrum. As the cotton is thus welded and pushed up, the room 
thus made is filled by new pledgets, until the vagina is dis- 
tended to its utmost and the tampon has reached not only the 
floor of the pelvis, but is parallel with the pubic arch. After a 
final thorough survey of the tampon, and packing down any 
loose parts, the dressing forceps hold back the cotton firmly 
with wide-spread blades, and the speculum is carefully removed 
with point backward. Considerable care is required not to 
dislodge the tampon in the manoeuvre, and it is necessary after 
removal of the speculum to fill the space thus made by a fresh 
packing tight of the whole tampon, and perhaps by several ad- 
ditional disks." 

We believe the tam- 
pon to be much more 
effectual when a plug 
of alum is placed with- 
in the os and held 
there by the packing. 
The tampon itself 
should be prevented 
from slipping away, 
by means of a T band- 
age. 

Separation of the 
Placenta.— This is a 
mode of treatment 
which has met with 

some success and 
Fig. 249. — T bandage to hold Tampon. (Bailly.) A— __ 

ia\ or. 

Cofnplete Separation . — Entire separation of the placenta as 

a mode of treatment, in certain cases, was first recommended 

by Simpson. He advised it more especially— 

1. When the child is dead. 

2. When the child is not viable. 

3. When the hemorrhage is great, and the os uteri is not yet 
sufficiently dilated to admit of safe turning. 

4. When the pelvic passages are too small for safe and easy 
turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the liquor amnii fails to arrest 
the hemorrhage. 




Parturient Anomalies. 527 

7. When the uterus is too firmly contracted to allow of 
turning. 

The practice was based on the theory that the source of the 
hemorrhage in placenta prsevia is chiefly the separated uterine 
surface of the placenta ; but, whether the theory be true or false, 
we sometimes find the operation a wise one. Complete sepa- 
ration of the placenta, however, is not easily effected, since the 
finger is not long enough to accomplish it. It may be done 
when necessary by introducing the half hand, or by careful use 
of a sound. 

Partial Separation.— Barnes divides the uterine cavity into 
three zones, or regions. When the placenta occupies the upper 
or the middle zone, there is no unavoidable hemorrhage. But 
when the placenta is partially, or entirely, in the lower, or 
cervical zone, expansion of the os uteri to its full dimensions 
involves more or less separation and consequent loss of blood. 
If but partially within the lower zone, the placenta may not be 
entirely separated, but, after expansion of the os has been 
accomplished, contraction of the uterine tissues will take place 
and seal the exposed vessels without further hemorrhage from 
the remainder of the placenta which lies above the region of 
unsafe attachment. 

Dr. Matthews Duncan assumes the limit of spontaneous de- 
tachment, as the result of uterine expansion, to extend two 
and one-fourth inches on every side of the center of the os uteri, 
and on the strength of this assumption Dr. Barnes has 
proposed a mode of treatment which is doubtless efficient 
in many cases, the description of which is given in his own 
words. 

"The operation is this: Pass one or two fingers as far as 
they will go through the os uteri, the hand being passed into 
the vagina if necessary; feeling the placenta, insinuate the 
finger between it and the uterine wall ; sweep the finger around 
in a circle, so as to separate the placenta as far as the finger can 
reach ; if you feel the edge of the placenta where the membranes 
begin, tear open the membranes freely, especially if these have 
not been previously ruptured ; ascertain if you can what is the 
presentation of the child before withdrawing your hand. Com- 
monly some amount of retraction of the cervix takes place 
after this operation, and often the hemorrhage ceases. * * * 
If uterine action return so as to drive down the head, it is pretty 
certain there will be no more hemorrhage; you may leave nature 



528 Labor. 

to expand the cervix and to complete the delivery. The labor, 
freed from the placental complication, has become natural." 

In event of failure to arrest the flow by this means, he recom- 
mends the use of his "uterine dilators," otherwise known as 
"Barnes' bags." 

A Full Bladder.— It is especially incumbent on the physician, 
in the treatment of placenta prsevia, to see that the bladder 
does not become loaded with urine. The patient's anxiety and 
fear, coupled with the pain and distress she suffers, may so 
divert her attention that the discomfort of a full bladder will 
be disregarded. In no case, however, should she be permitted 
to arise or materially change her position in order to perform 
the required act of micturition. It is far better to use a 
catheter than to allow this. 

Treatment After Moderate Dilatation of the Os. — We 
come now to consider the means of effecting delivery when once 
the os uteri has attained the state of dilatability which will 
admit of artificial aid, other than that already described. The 
character of the means suitable to the case will depend largely 
on the peculiar circumstances and conditions manifested in indi- 
vidual instances. In a certain proportion of all cases, the 
labor, from the moment of uterine dilatation, may be safely left 
to the natural efforts. The employment of the means for arrest 
or prevention of excessive hemorrhage before recommended, 
will often be so effectual as to obviate the pressing necessity for 
any further artificial interference. There is a point sometimes 
observed in these cases, beyond which to go would perhaps con- 
stitute "meddlesome midwifery." In the main, however, we 
find it necessary, in order best to conserve the patient's interests 
and rescue her from jeopardy at the earliest possible moment, 
to complete the delivery as rapidly as is compatible with the 
low state of the vital forces and the integrity of the tissues 
upon which the strain in rapid delivery mainly falls. 

Ergot has been recommended and successfully employed in 
those cases wherein uterine contractions are too feeble to force 
the fetus onward. We should refrain from exhibiting it if there 
still remains the possible necessity for version; if any obstacle 
to speedy expulsion exists, which could not be easily overcome 
by forcible contractions ; or, finally, if the forceps are not under 
ready command, and the case is not clearly suitable to their use. 

The Forceps. — The forceps, in dexterous hands, may be used 
early, and the woman thus speedily rescued from her perilous 



Parturient Anomalies. 529 

situation. The conditions upon which the difficulty in using 
them in placenta praevia mainly depends, are, the height of the 
presenting part, the partial expansion of the os and the inac- 
cessibility of the head from the unusual situation of the 
placenta. 

It is often perplexingly difficult to apply the forceps to the 
head when it lies free above the pelvic inlet, and to do so it may 
be found necessary to carry the half-hand into the vagina to 
give direction to the blades. The spiral sweep of the instru- 
ment, as it enters, must be observed, in order to acquire a firm 
hold of the head, which part might otherwise be so displaced 
as to prevent a satisfactory application. 

It is only under exceptional circumstances that we are justi- 
fied in applying the forceps through an incompletely dilated os, 
and those attending unavoidable hemorrhage constitute an in- 
stance. They who have never passed the instrument through a 
small os will find, on attempting to do so, that, in point of 
difficulty, it far exceeds an ordinary application. To perform 
the act with success, the details of application, elsewhere given, 
are required to be observed . 

The placenta, lying centrally, or laterally, over the partially 
expanded os, is a serious obstacle to this form of delivery. If 
the implantation is central, we may succeed in applying the 
instrument directly through the placenta, as has sometimes 
been done. To do so, an aperture must first be made of sufficient 
size to admit the blades, and then we may operate much as we 
would through a simple undilated os uteri. In such a delivery 
the placenta is likely to become loosened and be brought away 
in advance of the descending foetus, in which case the result will 
practically correspond to separation and extraction of the 
placenta. 

Incomplete placenta praevia is the form to which the forceps 
are more peculiarly adapted, as it is usually possible to turn 
aside the placenta and thus reach the foetal head. To accom- 
plish this the fingers should be slipped within the os uteri, and 
the direction in which there is least attachment carefully sought. 
Having found it, the placenta should be drawn aside, the mem- 
branes ruptured, and the blades passed. 

It is unwise, as a rule, to apply the forceps through a rigid os 
uteri, but the co-existence of placenta praevia sometimes consti- 
tutes an exception. Hemorrhage may be continuous, and still 
the os, from exceeding nervous irritability, may be spasmodi- 
(34) 



530 Labor. 

cally closed. Ordinary measures for relief are, perhaps, tried in 
vain. If dilatation has reached a degree which will admit of 
the forceps being introduced, rather than to suffer longer delay 
we may carefully proceed to deliver. Traction should not be 
really intermittent in these cases, but remittent, to avoid the 
possibility of recurring hemorrhage from a relaxation of the 
pressure imposed on the bleeding vessels during traction. 

Version. — Version, as a preliminary to extraction, in un- 
avoidable hemorrhage, was first suggested by Ambrose Pare, 
and afterwards practiced and strongly advocated by GuillemeaUo 
At present it is the most common mode of treatment, and some 
writers on the subject are so emphatic in their endorsement of 
it as to teach that every thought of placenta prsevia should 
have the idea of version associated with it. 

The conditions favorable to the performance of version by 
the internal method, as enumerated by Dr. Tyler Smith, are 
"a dilated or dilatable state of the os uteri; the retention of 
the liquor amnii, or a moderately relaxed state of the uterus; 
a pelvis of average capacity; the absence of dangerous ex- 
haustion, or a temporary cessation of the hemorrhage." 
"Nothing," says Leishman, "is of greater importance than 
that the operation should be attempted as early as possible, 
for there can be no doubt that the great mortality which at- 
tends these cases is due, in no small degree, to an injudicious 
expectant treatment, while the precious moments pass during 
which alone we can save the patient's life and that of her child." 
In order, then, to improve the golden moment for operation, we 
must be on the alert from the earliest manifestation of unto- 
ward symptoms. When a concurrence of the above mentioned 
favorable conditions is met, podalic version may be easily per- 
formed ; but the combination does not always exist, and then 
the difficulties are both numerous and formidable. 

There are two modes of performing internal podalic ver- 
sion, differing in the precise manner of passing the hand. In 
one, the hand is pressed gently into the vagina, and then 
through the os uteri and the placenta which lies over it. In the 
other, instead of making an aperture for the hand through the 
placenta, this organ is raised on the side of least attachment. 
In case of complete placenta previa, the hand is insinuated be- 
tween the organ and the uterine walls, and then between the 
thin membranes and the uterus, until a point opposite the feet 
is reached, when the sac is ruptured, and the extremities are 



Parturient Anomalies. 531 

at once seized. Serious objections to passing the hand through 
the placenta, as advocated by Dr. Rigby, have been raised by 
different obstetricians, and are concisely stated by Dewees as 
follows : 

"1. In attempting this, much time is lost that is highly im- 
portant to the patient, as the flooding unabatingly, if not 
increasingly, goes on. 

"2. In this attempt, we are obliged to force against the 
membranes, so as to carry or urge the whole placentary mass 
towards the fundus of the uterus, by which means the separa- 
tion of it from the neck is increased, and, consequently, the 
flooding augmented. 

"3. When the hand has even penetrated the cavity of the 
uterus, the hole which is made by it is no greater than itself, 
and, consequently, much too small for the foetus to pass through 
without a forced enlargement ; and this must be done by the 
child during its passage. 

"4. As the hole made by the body of the child is not suffi- 
ciently large for the arms and head to pass through at the same 
time, they will consequently be arrested ; and if force be applied 
to overcome the resistance, it will almost always separate the 
whole of the placenta from its connections with the uterus. 

"5. That, when this is done, it never fails to increase the 
discharge, besides adding the bulk of the placenta to that of 
the arms and head of the child. 

" 6. When the placenta is pierced, we augment the risk of the 
child, for, in making the opening, we may destroy some of the 
large umbilical veins, and thus permit the child to die from 
hemorrhage. 

"7. By this method we increase the chance of an atony of 
the uterus, as the discharge of the liquor amnii is not under due 
control. 

"8. That it is sometimes impossible to penetrate the 
placenta, especially when its center answers to the center of the 
os uteri ; in this instance much time is lost that may be import- 
ant to the woman." 

Explicit rules for performing podalic version will be given in 
another place, and we shall here indicate only the general out- 
lines of the operation as adapted to these cases. 

By locating the sounds of the foetal heart, we can determine 
with certainty towards which side of the mother lies the foetal 
back, and thus make choice of the hand with which the opera- 



532 Labor. 

tion can more easily be performed. Oiling the hand on its 
outer surface, it is passed within the vagina, and then slowly 
between the uterus and placenta, and the uterus and mem- 
branes, until it reaches a point opposite the child's feet. The 
membranes should then be ruptured and the feet secured and 
drawn downwards until version has been fully accomplished. 
After once the hand enters the os uteri, the hemorrhage is 
arrested by the temporary plug, consisting of the hand, the 
wrist, the forearm, and, ultimately (with a reversion of this 
order), the body of the child itself. 

Podalic version, always a formidable operation, is doubly so 
in such emergencies, owing to the excessive depression of the 
vital force by which, in most cases, it is preceded 

Many years ago the accoucheur was enjoined by Meigs, in 
his emphatic way, never to think of placenta prsevia without at 
the same time thinking of podalic version, which he regarded 
as the form of treatment par excellence. The method of version 
then in vogue was what we now call the ''internal," and this 
continued to be the one chiefly in use until a few years ago, when 
that by conjoint manipulation began rapidly to substitute it. 
In 1865, Braxton Hicks published a small work upon the sub- 
ject of Combined External and Internal Version, which attracted 
wide attention. It was not until some time after this, how T ever, 
that his method became extensively practiced. It is now 
generally recognized as the preferable mode of performing ver- 
sion in these cases, and version itself is still regarded as the 
best form of treatment. 

One very great advantage to be derived from the Hicks 
method is the possibility of performing version by means of it 
much earlier in labor than by the internal method. A second 
important one is found in the avoidance of complete introduction 
of the hand within the uterus. 

The woman upon whom it is to be undertaken should be put 
under anesthetic influence and drawn well to the edge of the 
bed, as in a case of forceps delivery. The hands of the operator, 
and the vulva and vagina of the patient, having been well 
cleansed with an antiseptic solution, manipulation is begun by 
introducing the half hand into the vagina, and the fingers 
within the os, while the other hand is placed upon the abdo- 
men to aid in the manoeuvre. It is not necessary that the os 
be wider than a nickel, or at the most, a silver quarter, just 
broad enough, in fact, to receive one or two fingers; but it 



Parturient Anomalies. 533 

is not good practice to force a single finger through the os for 
this purpose. If the placenta is central, it may be necessary to 
push the fingers through it, but, if a margin can be reached, 
there the membranes should be ruptured and the manipulation 
begun. 

Manipulation consists in pushing the presenting part up- 
wards and to one side, while the opposite extremity is crowded 
downwards and towards the opposite side, until a foot can be 
reached and drawn through the vagina. It is neither neces- 
sary, nor usually advisable, to effect immediate delivery, but the 
body of the child should be brought down into the os so as to 
serve as an effectual plug, while at the same time it presses 
firmly on the separated placenta and controls hemorrhage. 

Thenceforth the labor may be committed to the natural 
forces, reinforced, or not, by slight traction on the foetal 
extremities. 

The author of this method of managing placenta praevia 
has had great experience, and any instruction which he 
may give is entitled to peculiar weight. In November, 1889, he 
gave the following explicit directions concerning the treatment 
of this formidable complication of labor in its varying phases : 

"I think we shall all agree : First. That when the placenta 
is inserted somewhere within the lower third of the uterus, there 
is very generally a liability to hemorrhage. It would be diffi- 
cult to say that it is absolutely ' unavoidable/ because I have 
seen the placental edge a little over the os without the slightest 
bleeding, and doubtless there are cases of what is called ' acci- 
dental hemorrhage' which have occurred with a low insertion 
of the placenta. But I take it that for practical purposes, when 
the placenta is inserted about or over the os uteri, hemorrhage 
is to be expected before or upon the supervention of labor, 
whether premature or at full time. 

"Second. Most of us will agree that when once hemorrhage 
has declared itself, there is no security for the patient, but that 
her life is in imminent danger from liability to recurrent 
bleedings. 

''Third. My experience teaches me, that the relative posi- 
tion of the placenta to the os has no influence on the frequency 
or quantity of the blood-loss. In other words, whether it be 
marginal obstruction or central, the risk is the same. 

"If you join assent with me so far, I would submit this 
proposition as a deduction from the foregoing, as a rule of 



534 Labor. 

practice, namely, that as soon as we ascertain the case to be 
one of placenta prsevia, we should make arrangements for 
terminating the pregnancy at the earliest possible time. As far 
as possible, we should not leave our patient, certainly not to 
an indefinite future. 

"Our next consideration is, in what way and by what 
means we shall accomplish this. First, we desire to prevent 
further bleeding. Second, we wish to overcome the resistance 
the substance of the placenta presents to the passage of the 
foetus. 

"But also we cannot in the majority of these cases leave out 
of consideration the state of anemia which the patient pre- 
sents from the hemorrhage which has already occurred ; some- 
times so profound that the smallest movement, even ordinary 
examination, extinguishes the pulse. Of course, in all cases, it 
behooves us to carry out our manipulations with as much gen- 
tleness as possible, choosing, especially in the severer cases of 
anaemia, that plan the least disturbing. 

"The bleeding can be stopped by pressure; either by tam- 
pon ; by the head pressed down by the uterine efforts, or drawn 
down by the forceps ; or by the leg and breech drawn down if 
presenting, or made to present by turning. 

" With regard to the pressure by the tampon, I believe gen- 
eral consensus is against its use, and with this I am in accord; 
partly because, unless perfectly done, and this is difficult, it is 
of no use ; and if perfectly done, it is very distressing to the 
patient, especially if it is necessary, which it often is, to renew 
it to avoid septic generation. Still, it has advantages, because 
by distending the roof of the vagina we also dilate the os, and 
provoke uterine action. But its action is tedious, and lacks 
the precision afforded us by the more recent method. 

"But the uterine action alone will occasionally suffice to 
produce sufficient pressure on the inner surface of the placenta 
to stay bleeding, though it requires the head to be entering the 
os before it can efficiently do this ; so that if we found the os 
uteri fully dilated, the placenta marginal and the membranes 
tense, we might rupture the membranes, and if the head de- 
scended we should not expect further bleeding, and the case 
may be allowed to end naturally. But practically speaking, 
these cases are not the most frequent. If the placenta were 
mainly over the expanded os when the membranes were rup- 
tured, the head retarded by the bulk of placenta would not 



Parturient Anomalies. 535 

effectively enter, and then it would be our best plan to press 
the flap of placenta aside, and apply forceps, drawing down 
head into os, retaining it there by gently hanging on to the for- 
ceps till the pains were sufficient to expel the head, assisting 
them by gentle traction. 

"But it is very possible that we may have no forceps, and 
for one reason or another the head is unable to enter the os ; 
then we are under the necessity, in order to place our patient in 
safety, to bring the breech to the os by turning. This can be 
accomplished by either slowly pushing the hand through the 
os, seizing the leg, and bringing the breech into the os ; or by 
the combined external and internal version, effecting the same 
result in a gentler way. Of course, if the breech present origi- 
nally all that will be needful will be to bring down the leg, fix- 
ing the breech in the os. The hand should retain hold of the 
leg, so that the weight of the arm gives pressure sufficient to 
prevent further bleeding. The great object of these manceuvers 
is to produce pressure enough to check bleeding, and this press- 
ure need not be much. In both the employment of the forceps 
and in turning the action is not for instant delivery ; as soon 
as the os is plugged by head or breech, the object is accom- 
plished, a little additional traction, as the pains come on, sufficing 
for the delivery, which may be left mainly to nature. Thus we 
gain time, valuable to the patient, wherein we can sustain her 
energies, while the circulation recovers its balance. When the 
os is fully expanded, the engaging firmly of head or breech is 
followed in an hour or two by uterine action. Supposing the 
os is not sufficiently expanded to introduce forceps or to readily 
turn, then the os uteri can be expanded by the dilating bags, 
or, in the event of our not having them, the os could be gently 
dilated by the fingers introduced one by one. But if the os is 
so small as that, then 1 think the best plan would be to proceed 
by the combined method of version, as the leg and breech being 
of conical form it assists dilatation, and as the os expands it 
keeps up a corresponding pressure on the bleeding surface, for 
it has been constantly found in a large number of cases, that if 
very slight traction is kept up just at first no further bleeding 
has recurred. 

" If with all these states of os uteri, particularly if small, the 
placenta be attached more or less across, it is of much advan- 
tage to separate gently the placenta for a forefinger's length. 
This very distinctly releases the low T er portion of the uterus 



536 Labor. 

from the restraint caused by the attachment of the placenta, 
and this is very noticeable if the margin of the placenta be 
across the os, because the margin is the part most firmly ad- 
herent to the uterus. At the same time the flap of the placenta 
somewhat retracts, and is pushed aside as the head or breech 
descends. If the membranes are perfect then they need not be 
ruptured till the act of version, and when this occurs a still 
further easement is felt in respect of the rigidity. 

" Now with respect to the detachment of the placenta from 
around the os, the act of doing it may be attended with severe 
and continuing hemorrhage, particularly in central insertion of 
the placenta. In two cases which occurred to myself with 
central insertion, I was alarmed at the large flow, and this was 
only restrained by penetrating the center of the placenta, per- 
forming version and bringing the leg through the os, which was 
so small that scarcely two fingers could enter. 

"I would call attention to the practical fact that sometimes 
in detaching the placenta we have severe bleeding, whilst at 
other times we may not; indeed, these cases are the more 
frequent, and it has practically been found that a free, bold 
detachment of the placenta, as far as the finger can reach, has 
the effect in a large number of cases of checking the bleeding for 
a time, and thus we come to another means of restraining 
bleeding in placenta praevia. But inasmuch as by this action 
we have the placenta partially detached, and as our experience 
tells us that both in ' accidental' and post-partum hemorrhage 
there is with partial detachment liability to floodings, so when 
we employ this method as one which will give us time by 
temporarily restraining bleeding whilst the os uteri is dilating, 
yet we must treat it as a measure itself requiring supervision. 
This my experience bears out. In other w T ords, it is imperative 
that we should be in close attendance on the patient, ready to 
act should any bleeding of importance occur ; the action indi- 
cated being of course either to bring the head down by forceps, 
or breech by turning. We must also remember when we detach 
the placenta we cut off the foetus from its aeration to the same 
amount, and although it may be said that when it comes 
through the os about the same amount of placenta will be 
made useless by pressure, yet it may be rejoined that the effect 
of the detachment will generally extend many hours longer than 
that of the pressure. If the placenta be inserted more or less 
centrally, these considerations do not enter, for the placenta 



Parturient Anomalies. 537 

sooner or later must be detached to an extent probably fatal 
to the child 

"I would suggest here that in order to lessen the bleeding on 
detaching the placenta, the finger be kept close to the uterine 
surface, rather pressing it from the surface of the placenta than 
the placenta from the uterus. If this plan does not lessen the 
loss from the maternal side it will prevent loss from the fcetal 
villi, which must occur when we lacerate the placenta. 

"Now there are a certain class of cases, practically the more 
numerous, in which there has been severe loss, and it is neces- 
sary to secure the safety of the patient, but where the os is so 
small that we cannot put in operation the foregoing plans, so 
also where, although the os uteri be somewhat expanded, we 
have at hand neither forceps nor dilating bags, or where in 
peeling off the placenta we are confronted with alarming blood 
loss ; in these cases the only plan we have at command is ver- 
sion by combined internal and external method, and it is in 
these cases we see its great advantages. But when this method 
of version is used it must always be understood that it is not 
the version itself which is the haemostatic remedy, but that by 
it we are enabled to bring the foetal breech down on the 
placenta from within, and so are able at an earlier date than 
otherwise possible to stay the flow. It is possible in some cases 
to dilate the os with fingers, and after some time and with 
more or less force to pass the hand through theos and so reach 
the leg, but I feel quite sure that anyone who has tried the two 
plans will without hesitation pronounce in favor of version by 
the newer method, and it is interesting to note that, although 
very little or no uterine action was observed before turning, yet 
shortly after the leg has been brought in through the os the 
pains commence and continue, so that labor is accomplished 
without requiring much assistance from the attendant often 
within a couple of hours. 

"In selecting our plans for the safety of the mother we can- 
not leave out of consideration the preservation of the child so 
far as possible ; and here I think we shall all agree in choosing, 
where the state of the os, the position of the placenta, and the 
condition of the mother permit it, delivery by the head as the 
most likely to secure its safety, that is to say, with a fulty ex- 
panded os and placenta marginal. But when the os is only 
large enough for two fingers, and the placenta much across the 
os or central, the time which elapses before labor is over, and 



538 Labor. 

the great reduction of its aeration adds so much to its jeopardy, 
that the extra risk produced by pressure on its funis as the 
result of turning is scarcely to be taken into calculation. In 
either case the death-rate is very high. But if for any reason 
there has been laceration of the placenta there will also be 
laceration of the villi, and in consequence an oozing of blood 
will be going on serious to the vitality of the child, if it be free 
or continuing during long hours whilst we are waiting for the 
expansion of the os and pressure of the head, so that risk by 
pressure on funis after turning is, I think, pretty evenly bal- 
anced in the other mode by the loss of its blood. If after 
gently detaching the placenta just enough to set free the lower 
portion of expansion we quickly bring the leg or breech into the 
os, all loss from the placenta is checked, as it is at the same 
time from the maternal vessels. In all cases of placenta prsevia 
before end of seventh month, and where we know foetus is dead, 
of course the question of preserving foetal life does not arise. 

"In those cases where the anaemia is so profound that almost 
the least movement eclipses the pulse, our difficulties are very 
great, but whatever we do we must do it with extreme gentle- 
ness. Our first object is of course to prevent farther loss while 
we sustain the powers by restoratives and till the circulation 
recovers its balance. If there be no bleeding we had better wait, 
but keeping watch at the bedside in case it return. Should it 
do so, or when the patient has rallied, we may elect to use for- 
ceps or combined version, according to circumstances. But as 
detachment of the placenta may be attended by more or less 
blood-loss, I should not advise this method. But these cases 
are so formidable, that often before we see them their fate is 
sealed, and while we are waiting for the rallying, already coag- 
ula in the heart have formed, and slowly but surely block the 
current." 

When examination discloses a presentation of the pelvic ex- 
tremity of the child, whether it be breech, feet or knees, we may 
vary somewhat the practice usually advised in such cases, by 
bringing down a foot. As the characters of the presenting part 
in placenta prsevia are obscured by the interposed placenta, 
they cannot generally be made out until the time for interfer- 
ence arrives, and the hand is passed into the vagina for opera- 
tive purposes. In pelvic presentation, we have, then, but to 
proceed and bring down a single foot, or both feet. 

In the treatment of unavoidable hemorrhage during de- 



Partukient Anomalies. 



539 



livery, or before, we can expect but little aid from drugs 
administered in any form. If the woman's energies are broken, 
and the uterus is inactive, by the exhibition of china, Pulsatilla, 
secale, camphor, or caulophyllum, some help may be given. 
China ought to be exhibited in every case of excessive blood- 
loss. If the os uteri is spasmodically closed, belladonna, 
gelsemium, aconite, or caulophyllum may mollify it. But none 




Fig. 250.— Prolapse of the Umbilical Cord. 

of these remedies can have direct influence over the hemorrhage 
itself, which constitutes the alarming symptom. 

After labor our remedies will be of great service. 

Prolapse of the Funis.— This is a complication which does 
not in any manner retard the labor or make it difficult, but 
what gives it significance is the danger in which its occurrence 
places the foetus. A loop of the cord descends by the side of the 
presenting part, and is liable to severe compression between the 
foetus and the pelvic walls. The consequence of such an acci- 
dent is serious interruption of the foetal circulation, and de- 
struction of the child from asphyxia. 



540 Labor. 

Frequency of Occurrence. — It is not generally regarded as 
of frequent occurrence, but it is probable that moderate pro- 
lapse takes place in some cases without detection, and results 
in foetal death. A loop of cord may descend far enough to 
suffer compression at the superior strait without being detected 
in an ordinary vaginal examination. It has been observed 
once in 300 or 400 cases. 

Massmann estimated the frequency of the prolapse as fol- 
lows : 

In head presentations .... 0.67 or 1 : 150. 
In breech " ..... 4.70 " 1 : 21. 
In transverse " 8.5% " 1 : 12. 

Playfair and others have called attention to its remarkable 
prevalence in certain districts, attributing the phenomenon 
mainly to the unusual number of rachitic pelves in such places. 
As between France, England and Germany, it is least frequent 
in France and most frequent in Germany, the respective figures 
being 1 in 446%, and 1 in 207%, and 1 in 156. Simpson believed 
that these national differences are occasioned mainly by the 
varying positions in which women are placed during labor, but 
this interpretation of the causative influences which are respon- 
sible for such widely different experiences, seems to lack the 
strength of probability. 

Prognosis. — To the foetus, prolapse of the funis is one of the 
most serious possible complications of labor. In 355 cases col- 
lected by Dr. Churchill, 220 children, or nearly two-thirds, died. 
These, however, were mainly hospital cases, and it may be that 
in private practice the mortality is not quite so great. 

Out of 743 cases compiled from various authorities by 
Scanzoni, only 335 of the children were saved. Out of 202 
cases of vertex presentation with prolapse of the funis, tabu- 
lated by another, only 76 children were saved. 

It is evident that compression of the cord is the main cause 
of so heavy a death-rate ; but some authors attributed it in part 
to partial loss of fluidity of the blood from being chilled as it 
passes through a loop of cord which protrudes from the vulva. 
This effect of exposure has been questioned by many, among 
them Madame Lachapelle, who says, "I have seen the cord 
hang out of the vulva for several hours together without the 
foetus suffering therefrom in anywise, because there was no com- 
pression ; and this, in some of the cases, notwithstanding the 



Parturient Anomalies. 541 

patients had come a greater or less distance, either on foot or 
in some vehicle, from their residences to our hospital." The 
writer has likewise recently delivered a woman in whose case the 
cord had been prolapsed for two or three hours, and when felt, 
seemed cool and pulseless, and still the child, though feeble, was 
easily revived. 

It is evident that the prognosis depends on a variety of con- 
ditions, among which we may mention, the nature of the pres- 
entation, the degree of descent, the period in labor when it 
occurs, the state of the membranes, the interval between the 
occurrence of prolapse and its recognition, and the method of 
treatment employed. 

Causes.— Prolapse of the funis results from a variety of 
causes, among which are unusual length of the cord itself, a re- 
dundancy of liquor amnii, irregularities of the pelvic brim, 
obliquity of the long uterine axis, positions and presentations 
of the foetus which do not occupy the full outline of the pelvic 
brim, and low attachment of the placenta. In the front rank 
of proximate causes we must place sudden and rapid escape of 
the liquor amnii. In most cases of labor, the presenting part 
presses well down on the brim, and rupture of the membranes 
during a pain is attended with escape of only that part of the 
amniotic fluid which is confined below. But, in other cases, the 
presenting part does not rest at the brim with so firm and 
equable a pressure, and when the bag of waters breaks, a large 
part of the liquor amnii escapes with a gush, and may bring 
down with it a loop of the cord. 

Signs of Funis Presentation. — The signs of prolapse of the 
umbilical cord are usually sufficiently well marked to make 
diagnosis easy. Descent is often so great that a loop of the 
cord, three or four inches in length, protrudes from the vulva. 
Pulsation may be present or absent. When present, it is some- 
times so feeble as almost to escape detection. If pulsation be 
distinctly felt, this alone will establish the diagnosis. If absent, 
the twisted arrangement of the vessels, always plainly felt, or 
visual examination, will remove all doubt. When only a piece 
of the loop can be felt at the brim, it may be mistaken for a 
finger or toe, unless the examination be pressed. It seems 
hardly credible, but a loop of intestine, prolapsed through a 
rent in the uterus, in more than one instance has been mistaken 
for the umbilical cord. 

When only a knuckle of the cord drops down below the brim, 



542 



Labor. 



it is so small that it may escape attention, and the child be 
sacrificed through neglect, without a suspicion of danger. 

Has Pulsation Ceased ?— It is of the utmost importance 
that, in prolapse of the funis, we determine whether or not the 
cord be pulsating, since if pulsation has actually been absent 
for say fifteen minutes, we are safe in assuming the child to be 
past recovery, and need resort to no interference on account of 
the complication. Mere inability at once to detect pulsation is 
not sufficient ground upon which to rest the expectant treat- 
ment. It is remarkable how soft and indistinct are the pulsa- 
tions in some cases, as the author has recently had occasion to 
observe. It should be remembered in this connection that an 
examination of the cord made during a pain is liable to mislead, 

as compression at such a 
time may be sufficiently 
great to interrupt the cir- 
culation, while in the inter- 
val between pains circula- 
tion may be unimpeded. 

Treatment.— Prolapse 
of the umbilical cord con- 
stitutes a real emergency, 
inasmuch as even a brief 
delay in affording relief 
may be fatal. The obvi- 
ous aim of treatment is 
to prevent or relieve com- 
pression of the cord, which 
may be accomplished through the following means : 

1. Prevention of descent in threatening cases ; 

2. Reposition of the cord when prolapse exists; 

3. Protection of the prolapsed cord when reposition cannot 
be effected ; 

4. Version as a substitute for reposition. 

Prevention of Prolapsus. — This has but a brief range of ap- 
plicability. Before rupture of the membranes, in the first 
stage of labor, the cord may occasionally be felt, coiled in ad- 
vance of the presenting part, and ready to descend as soon as 
rupture occurs. In such a case the membranes should be care- 
fully preserved, and the woman placed in a posture favorable 
to spontaneous return of the cord to a less exposed situation. 
We allude to the posture about to be described, which is like- 




Fig. 251.— Inclination of the Uterus, in 
the dorsal posture, favoring descent of 
the Cord into the pelvis. 



Parturient Anomalies. 



543 



wise of the utmost value in attempts to reposit the cord after 
prolapse has really taken place. 

Reposition. — So long as the woman occupies a position on 
her side or back, the cord, from its very weight, will manifest a 
strong disposition to return after every reposition. The 
tendency can sometimes be overcome by carrying it deeply into 
the uterine cavity, but this may involve introduction of the 
hand. "We should not hesitate," says Tarnier, "to carry the 
hand up to the fundus of the womb for the purpose of leaving 
the prolapsed portion in that part of the organ." It occurred 
to Dr. T. Gaillard Thomas to invert the uterus, and thereby 
bring the force of gravity in the direction of the fundus, by 
placing the woman in the knee-elbow, or, better still, in the knee- 




Fig.252. — Postural treatment for prolapse of the Cord. 

chest position. The anterior uterine wall is thereby made to 
form an inclined plane down which the cord slips. With the 
woman in this posture it is in some cases found that the force 
of gravity alone is sufficient to restore the prolapsed cord, since 
the head or other presenting part ceases to press firmly on the 
brim, and nothing suffices forcibly to maintain the displace- 
ment. 

When the funis has thus been placed beyond the risk of com- 
pression, the forceps may be applied, and the head drawn into 
the brim, thus preventing a possible renewal of the complica- 
tion. If the forceps cannot well be used at this juncture, the 
head may be retained at the brim by firm hypogastric pressure, 
and the woman permitted to resume a less irksome position. 
The postural treatment is suitable to all cases wherein there is 



544 



Labor. 



any hope of restoring the cord to the uterine cavity ; but it will 
usually have to be supplemented by either manual or instru- 
mental aid. 

Whenever practicable, instrumental and manual reposition 
should be performed with the woman in the knee-chest posi- 
tion. 

The methods of reposition vary greatly. Tarnier, as before 
quoted, thinks it justifiable to carry the cord with the fingers 
as high as the fundus uteri, while others regard even the hollow 




Fig. 253.— Manual reposition of the Cord. (After Auvard.) (Woman in 

knee -chest position. 1 ) 

of the neck, in vertex presentation, as too elevated. Unfortu- 
nately, reposition, when thoroughly performed, is often ex- 
tremely difficult to effect, and exceedingly disappointing in its 
results. 

Various instruments have been devised to aid in the manoeu- 
ver, but few possess them, and fewer still can successfully use 
them. 

Among the most practical instruments for this purpose is a 
pair of dressing forceps with which the cord is seized, in the 
manner shown in the accompanying figure, and elevated to its 
position above the reach of compression. The forceps can then 



Parturient Anomalies. 



545 



be unlocked and withdrawn. Such an instrument requires care- 
ful manipulation to prevent injury of the maternal and foetal 
structures. 

The fact is, that, in most cases, relief must be afforded with- 
out the least delay, and the preparation of the ingenious means 
recommended in many text-books consumes the very time which 
determines the issue of the case. It is our opinion that in those 
cases wherein successful reposition is at all possible, the hand 
is a better instrument than any yet devised, and with it we may 
more safely press the cord into the uterine cavity, and maintain 
it there. To effectually carry out this 
sort of treatment, then, we should bear 
in mind the following points : 

1. The knee-elbow, or the knee-chest, 
position, for the woman. 

2. The use of the hand to return the 
cord, carrying it well into the uterine 
cavity. 

3. The immediate application of the 
forceps, or supra-pubic pressure to pre- 
vent recurrence of the complication. 

Protection. — Efforts at complete re- 
position often fail. Moreover, in a cer- 
tain number of cases the event proves 
that labor had advanced too far to 
admit of a return of the cord to a situa- 
tion high enough to escape compression, 
and this, too, in some instances, where 
there is good ground for hoping to save 
the child's life. Treatment will then in 
great measure be controlled by sur- 
rounding circumstances. 

Nor should we forget that prolapse 
of the funis does not always necessitate protracted interrup- 
tion of the foetal circulation. The cord may be in a protected 
situation, and if it is not, we may be able to place it there. If 
pulsation has not long been absent, and labor is progressing 
rapidly, it may be completed in a natural manner, in time to 
preserve the foetus. Again, if compression has not been long- 
continued, and the pelvic structures are in a favorable condi- 
tion, the forceps may be applied, and labor terminated without 
delay. 

(35) 




Fig. 254. — Reposition 
of the Cord with for- 
ceps. (Auvard.) 



546 Labor. 

Version.— If the head still lies free at the brim, and all 
efforts at reposition of the cord have failed, we may have re- 
course to version. Engelmann found that seventy per cent, of 
the children delivered in this way were saved. Decision is here 
a point of great nicety, since the operation of podalic version 
augments the maternal dangers. Statistics have not been 
gathered upon which to base a rule of action in such cases, and 
the matter is thus left entirely to the judgment of the practi- 
tioner. If version can be effected by the Hicks method, the 
objections would be measurably robbed of their force; but, 
unfortunately, this mode of operating, at such a time, is rarely 
practicable. "It is scarcely necessary to state," Engelmann 
emphatically says, " what figures so plainly show, that version, 
preceded by judicious postural treatment, is the method to be 
followed which promises most for the life of the child, in pro- 
lapse of the cord, when complicating head presentations." 

Accidental Hemorrhage. — This is a variety of uterine 
hemorrhage regarding which relatively little is found in the 
text-books, or even elsewhere in obstetrical literature ; yet it is 
of sufficiently frequent occurrence, and involves ample difficulty 
and danger, to merit more than passing notice. Its character, 
causes and treatment ought to be familiar to the student of 
midwifery. 

Its Character. — What does the term "accidental hemor- 
rhage" signify? In one sense we may justly regard every 
flooding as the result of accidental causes, but the designation 
here made is specific. The elder Rigby, more than a hundred 
years ago, clearly drew the lines of accidental hemorrhage, and 
established its distinctions. The term is employed more espe- 
cially to differentiate between two varieties of hemorrhage 
occurring at a like period in pregnancy, and presenting similar 
features. Accordingly there are "accidental hemorrhage," and 
"unavoidable hemorrhage," both encountered in the latter 
months of utero-gestation, and prior to foetal expulsion. The 
former often proceeds from accident, and from this fact the 
designation is probably derived. A profuse flow of blood 
occurring earlier than the seventh month does not acquire the 
title, it being recognized merely as a symptom of threatened 
abortion. 

It rarely occurs among young and vigorous women. 

The Relation of Fcetus and Placenta to the Uterus.— 
The placenta is in its usual situation, high up on the body of 



Parturient Anomalies. 547 

the uterus, or at its fundus, and the vascular relations of the 
several parts differ in no essential particulars from those recog- 
nized as normal. There are, in general, no anomalies in the 
arrangement of various parts, nothing perceptibly unusual in 
the relations of the foetus to the placenta, or of the placenta to 
the uterus, which could possibly render the loss of blood in any 
strict sense unavoidable. 

The Causes. — The immediate cause of the hemorrhage is an 
inconiplete dissolution of the utero-placental relations, and 
the consequent exposure of bleeding vessels. The remote 
causes— that is to say, the causes proposed to account for the 
placental separation — are often untraceable, but albuminuria 
is among them. In a certain proportion of instances, the 
mainspring of the broken relationship is plainly referable to 
accidental influences. The woman has suffered an unusual 
muscular strain from sudden motion, from lifting a heavy 
weight, or perhaps a light weight at disadvantage, from a long 
walk, from a high reach or a high step. Within a few moments, 
or hours, a flow of blood sets in, and a case of accidental hem- 
orrhage is rapidly developed. A blow upon the abdomen may 
fall on the site of placental attachment, and partial separation 
be produced. Even violent foetal movements may sever the 
utero-placental relations. During the latter part of pregnancy 
these relations are more feeble than at an earlier period, and it 
is surprising that they are not oftener prematurely broken. It 
is quite probable that in some women the connection becomes 
so infirm, that any unusual motion, or even ordinary locomo- 
tion, is sufficient to sever it. 

Varieties.— There are two varieties of accidental hemor- 
rhage, namely, the open and the concealed, or the external and 
the internal. In both, the flow is occasioned by partial sepa- 
ration of the placenta, and in both, blood is poured out be- 
tween the foetal envelopes and uterine walls. In one case it freely 
escapes through the os uteri, and in the other it meets an 
obstacle and remains pent up in the uterine cavity. The effect 
on the patient is much the same in either case, though con- 
cealed hemorrhage is attended with rather more danger, from 
the fact that its existence is not generally disclosed until ex- 
tensive depletion has resulted. 

Symptoms of External Hemorrhage.— The symptoms of 
the open variety are manifest, and generally exhibit diagnostic 
characters. Whether preceded or not by an injury or strain, 



548 Labor. 

bleeding begins, and at first is not necessarily accompanied by 
any other symptom of premature labor. 

If the loss of blood is but slight, it ought not to be dignified 
by the title of hemorrhage. During pregnancy, in nearly all 
stages, there is an occasional "show" of blood, which possesses 
no special significance. 

In connection with the flow there may be pressure in the sa- 
crum and abdomen, succeeded after a time by real recurrent 
pain. When profuse hemorrhage sets in during parturition, the 
uterine contractions usually become feeble, or entirely cease. 

Symptoms of Concealed Hemorrhage.— In the concealed 
form, blood is discharged between the membranes and uterine 
walls, or beneath the placenta, causing still greater separation. 
The exuded fluid is sometimes confined beneath the placenta, 
which remains attached only at its margins. A surprising 
quantity of blood is sometimes thus confined, causing consider- 
able, and even dangerous, distension. Dr. W. Goodell collected 
106 cases of concealed hemorrhage, and, from a study of their 
symptoms, deduced the following marked signs : 1. An alarm- 
ing state of collapse evinced by coldness of the surface, excessive 
pallor, feeble pulse, yawns, sighs, dyspnoea, restlessness, retch- 
ing, etc. 2. Generally, severe pain in the abdomen. 3. Marked 
distension of the uterus. 4. When occurring during labor, an 
absence or a feebleness of uterine contractions. In addition to 
these symptoms, there may be dimness of vision and syncope. 
Observing such signs, the hand is placed upon the abdomen, 
and remarkable distension is found. Pressure may force away 
the obstacle from the cervix, or separate the membranes or 
placenta wherein the flow is pocketed, and allow the pent-up 
blood to escape with a sickening gurgle. 

Madame Boivin had little faith in the possibility of fatal 
concealed accidental hemorrhage. "I cannot believe," she 
says, " that the uterus, filled with the product of conception, can, 
at any stage of gestation, admit so considerable a volume of 
blood, unless it has been recently emptied, nor can the quantity 
be sufficient to occasion the death of the woman." Yelpeau 
entertained a similar opinion. Dr. Meigs "never met with a 
sample of this kind of bleeding." But facts are always more 
forcible than theories ; and the evidence of fatal cases put upon 
record is a sufficient response. 

Differential Diagnosis. — Little difficulty is generally expe- 
rienced in differentiating between accidental and unavoidable' 



Parturient Anomalies. 549 

hemorrhage, but in order to make the distinctions explicit 
beyond a doubt, the following comparison has been arranged: 

ACCIDENTAL HEMORRHAGE. UNAVOIDABLE HEMORRHAGE. 

1. Often preceded by a blow, strain, 1. Earely preceded by an injury. 
or other injury. 

2. Most frequently sets in moder- 2. Generally comes suddenly and 
ately and, for a time, gradually in- profusely, but often lasts only a short 
creases. time. 

3. There is no history of previous 3. Hemorrhages, brief, but free, in 
hemorrhages of recent occurrence. a goodly number of instances, occur 

at intervals after the fifth or sixth 
month. 

4. If uterine contractions are pres- 4. The flow is more profuse during 
ent, the flow is more marked in the a contraction. 

intervals. 

5. The cervix uteri and neighbor- 5. The cervix and uterine walls, as 
ing uterine walls appear to be of felt through the vagina, are gener- 
normal thickness and feel. ally thick and doughy. 

6. If the os uteri will admit the 6. If the finger is passed through 
finger, the membranes maybe felt, the cervical canal it generally comes 
and through them, as a rule, the in contact with some part of the pla- 
presenting foetal parts. centa, which constitutes the present- 
ing part. 

Prognosis.— This is usually as bad as in connection with 
unavoidable hemorrhage. Guy's hospital reports show a 
maternal loss of about 26 per cent, and a fcetal mortality of 
66. GoodelPs researches disclosed a maternal mortality of 51 
per cent, and a fcetal mortality of 94 per cent. 

Treatment.— Rest in a recumbent posture, perfect quiet 
and freedom from excitement and irritation, must be enforced. 
The discreet use of cold may be sufficient to arrest the flow, or 
greatly modify it. The patient must be carefully guarded 
against disappearance of the external hemorrhage, and the 
occurrence of a concealed discharge. 

If the placenta has separated over only a small area, this 
treatment alone may be adequate; but if a considerable sur- 
face of so great vascularity has been exposed, more radical 
measures will be called for. It is manifestly desirable in acci- 
dental hemorrhage developed prior to the middle of the ninth 
month, to overcome the threatening symptoms, and, if possi- 
ble, prevent premature labor. 

The first question to be answered here, as in threatened 
abortion, is, — "Is expulsion inevitable?'' and if there is any 
likelihood of preventive measures succeeding, endeavors should 



550 Labor. 

be directed towards arrest of the symptoms, by such means as 
will not tend to promote the expulsive process. These are few 
and simple, and have, in the main, been indicated. Medicines 
can hardly be expected to have any direct control over the 
flow. Bleeding vessels are exposed, and, with the womb still 
distended by the product of conception, they cannot be con- 
stringed as they usually are under other conditions. 

The flow can be arrested, under the circumstances, only by 
the formation of coagula which will seal the vessels. Drugs, 
cannot be expected to do that ; but there is an indirect service 
which they can render, and that is to soothe the nervous and 
vascular excitement. To accomplish this, the law of similars 
is our best guide, though the use of morphia for the purpose is 
not to be condemned. The nervous tension may be subdued by 
coffea, stramonium, actwa, or ignatia, and the vascular excite- 
ment by aconite, veratrum viride, or belladonna. 

It should be remembered, also, that among the best sedatives 
at such a time are encouraging words from the medical at- 
tendant, and the exhibition of perfect self-possession. Should 
he evince agitation or alarm, his patient, however placid 
before, will become inoculated with the prejudicial ferment, and 
be made less responsive to curative influences. 

Pressure on the fundus uteri will sometimes modify, or wholly 
arrest, the loss. In applying it, much force must be avoided 
through fear that all hope of preventing premature labor may 
thereby be destroyed. 

If foetal expulsion is clearly inevitable, the measures described 
being inadequate to overcome the flow, or if the loss is at all 
alarming, every effort should be directed towards emptying the 
uterus. In the conduct of a case up to the time when preventive 
measures cease to be indicated, care is exercised to preserve the 
membranes intact; but now as an approved, and, in most in- 
stances, effective, mode of treatment, they are punctured or torn, 
and the liquor amnii drawn off. To do no more than merely 
rupture the membranes maybe insufficient, and hence, after pro- 
viding an opening for escape of the amniotic fluid, it is better, 
between pains, to crowd the presenting part away from the 
brim to permit complete escape of the fluid. By such an opera- 
tion the uterus is enabled to diminish its bulk, and by joint 
effect of condensation and compression it is often enabled to 
terminate the hemorrhage. " The puncture of the mem branes," 
says Dr. Barnes, "is the first thing to be done in all cases of 



Parturient Anomalies. 551 

flooding sufficient to cause anxiety before labor. It is the 
most generally efficacious remedy, and it can always be ap- 
plied." 

Occasionally the uterus is sluggish, and rupture of the 
membranes is not followed by the favorable effect so earnestly 
sought. In that case it must be aroused to action by kneading, 
by cold applications, by indicated homeopathic remedies, or 
even by ergot, pro vided the other conditions are favorable. The 
tampon ought not to be used in such cases unless it be inexora- 
bly demanded, and, if used at all, concealed hemorrhage must 
be sedulously guarded against. An expedient far preferable to 
tamponing, is pressure of the presenting part into the pelvic 
brim by means of the hands on the abdomen. 

•Delivery by the forceps, or podalic version, should be effected 
at the earliest practicable moment. If necessary, gentle manual 
dilatation of the os uteri may be practiced, until the hand can 
be introduced, or the instruments applied. The forceps are to 
be preferred in case the vertex constitute the presenting part. 
When once applied and traction begun, the special emergency 
has passed, and the very presence in utero of the blades will be 
likely to awaken the uterus to renewed activity, while at the 
same time the head is being steadily drawn into and through 
the pelvic cavity. If the forceps be not at hand, or cannot be 
speedily obtained, or if the presentation be face or transverse, 
then podalic version ought at once to be performed. The 
Braxton Hicks method may here be employed before the os has 
attained a size which will admit of forceps delivery, and much 
valuable time thereby saved. 

If, after rupture of the membranes, the hemorrhage be not 
arrested, and yet the os be found too small for operative pro- 
cedure, one of Barnes' bags maybe introduced to hasten dilata- 
tion, while the uterus is carefully watched to see if there de- 
velop evidences of internal hemorrhage. 

When the breech presents we may depart from the common 
course of treatment by bringing down a foot and drawing the 
foetal thighs into the pelvic cavity. This will enable the uterus 
to contract to such an extent as to control the hemorrhage, 
and then we can safely commit the case to the natural efforts. 
If, however, we have -good reason to distrust this hemostatic 
action of the uterus, delivery should be terminated without 
unnecessary delay. 



552 Labor. 



CHAPTER XV. 

OTHER PARTURIENT ANOMALIES ARISING IN THE FIRST AND 
SECOND STAGES OF LABOR. 

Rupture of the Uterus. — This most dangerous accident of 
labor is fortunately a comparatively rare occurrence. Burns 
calculates that it happens once in 940 labors. Ingleby, once in 
1,300 or 1,400; Churchill, once in 1,331; Lehmann, once in 
2,433; Jolly, once in 3.403; Ames, once in 4,883; and Harris, 
once in 4,000. It need not be said that, in these calculations, 
ruptures of the intra-vaginal portion of the cervix uteri, which 
are exceedingly common, are not included. In their immediate 
effects, the latter are rarely of much moment, though their 
baneful influence on the health of women has been clearly 
demonstrated . 

Seat and Character of Lacerations.— Rupture of the 
uterus takes place much less frequently in its upper part, but 
the site of placental insertion is rarely involved. The most 
common point of rupture is near the junction of the body and 
neck, either anteriorly or posteriorly. Laceration nearly 
always begins in the lower segment. In a few cases the cervix 
has been torn away from the body of the organ in the form of 
a ring. 

The laceration does not invariably penetrate all the struc- 
tures which go to make up the uterine wall. The peritoneum 
may wholly escape in one instance, while again it may be the 
only part involved, The tears vary also in length. Beginning 
as they usually do in the lower segment, they rarely extend 
high along the body of the organ, and more rarely still into 
the fundus, though they often extend downwards through the 
cervix, and may even implicate the vagina. 

The direction of laceration varies greatly, but it is usually 
either transverse or oblique. 

Time of Rupture. — This distressing accident is not con- 
fined to labor, but it has many times been known to occur 
during pregnancy. The early part of gestation is almost wholly 
exempt from it by reason of a lack of great distension and 
attenuation of the uterine walls. 

During labor the accident rarely happens early. 

Etiology. — During pregnancy the causes are a yielding 



Parturient Anomalies. 553 

cicatrix left after a Cesarean section, the thin wall of the rudi- 
mentary horn of a double uterus, direct violence, or an unusual 
muscular effort. 

Among the predisposing causes of the accident during labor 
we may mention abnormal thinness of the uterine walls, mor- 
bid conditions of the muscular fibers, such as accompany 
malignant and fibrous growths, fatty degeneration and the re- 
sults of injuries. Dr. Trask, who collected 417 cases, alluding 
to sixty-seven of them wherein the causes were assigned, says : 
" Of this number there were thirteen healthy, twenty softened, 
twenty-one thinned, one thinned and softened, three at some 
points thinned and at others thickened, eight diseased, one 
thinned and brittle." Multiparity appears to have a decided 
influence in the production of the accident. Charpentier says 
that multiparous uteri develop thinness and are reduced in 
power; but w r e believe that multiparous uteri are relatively 
more powerful, and that it is the very strength of their con- 
tractions which occasion the accident. 

Among the exciting causes of the accident, vehement action 
of the uterus occupies the most prominent place. Irregularity 
of the pelvic brim, unusual prominence of the sacral promon- 
tory, and osseous spiculae or more obtuse projections at any 
point on the inner surface of the pelvis, are disposed to lacerate 
or grind the uterus as the foetus is driven onwards through the 
pelvic canal. 

Lusk epitomizes Bandl's teaching on this subject substan- 
tially as follows : In normal labor, during each pain the fundus 
and corpus uteri thicken, while the lower part is stretched and 
thinned by the ovum or presenting part of the foetus. So long 
as no obstacle is met which hinders descent, the process ends in 
conversion of the uterus and vagina into one continuous canal. 
The lower circumference of the body is ordinarily distinguished 
in advanced labor from the stretched lower segment by a thick- 
ened ridge known as the" ring of Bandl," though in easy labors 
this feature is indistinctly marked. When descent is hindered, 
the resistance of the ligaments which hold the uterus in position 
is overcome by the continued retraction of the body and 
fundus, until, in extreme cases, the foetus may finally be almost 
w T holly embraced within the thinned walls of the lower uterine 
segment. Under these circumstances the contraction ring of 
Bandl becomes very distinct, and may sometimes be felt nearly 
as high as the umbilicus. This movement is somewhat limited 



554 Labor. 

by the uterine ligaments, and since they are more relaxed in 
multipara than in primiparse, it is not difficult to understand 
the relative frequency of rupture in women who have borne 
children. In exaggerated examples of this action, the walls of 
the lower uterine segment may be reduced to membranous 
thinness. 

Jolly collected thirty-three cases of uterine rupture resulting 
from undue force of uterine action excited by the injudicious 
use of ergot. 

Mechanical injuries are responsible for a good many of these 
accidents. The organ has been ruptured by falls and blows 
received in the latter part of gestation ; also from violence in 
the performance of certain operations, such as version and use 
of the forceps. 

Symptoms. — In some instances uterine rupture has been 
preceded by certain premonitory symptoms, such as unusually 
agonizing pain, accompanied by a sense of cramping in the 
hypogastric region, but, in the very nature of the case, such 
symptoms are of but little value as indications of what is about 
to follow, since they cannot be separated from the ordinary 
pains of a difficult labor uncomplicated by an impending 
accident of so fatal a nature. 

The severity of the symptoms necessarily depends in great 
measure on the extent of the rupture. Numerous cases have 
been reported in which post-mortem or other evidence of 
uterine laceration has been found, though the women during 
labor presented none of the alarming symptoms which com- 
monly accompany the occurrence. But there is usually a sudden 
sharp and excruciating pain, quite unlike the pains of labor, 
followed by well-marked indications of a serious accident. 
Then there is a recession of the head or other presenting part, 
when it is not tightly held at the brim, or lying in the pelvic 
cavity, and a sudden cessation of the recurrent contractions. If 
the laceration be extensive, the child commonly passes through 
it into the abdominal cavity, where its outline is easily dis- 
tinguishable through the abdominal walls. A coil of intestine 
may prolapse through the laceration and descend into the 
vagina. The symptoms of collapse at once supervene, blood 
gushes from the vagina, and the sounds of the foetal heart 
cease. 

The real character of the occurrence is in some cases masked 
by the maintenance of strength, the presence of the presenting 



Parturient Anomalies. 555 

part at the brim, and the continuance of fair pains. Fatal 
symptoms may not develop until after the lapse of some hours, 
or even days. 

Following are the results of Jolly's study of 580 cases with 
respect to the symptoms manifested after rupture : 

Abrupt cessation of uterine contractions observed in 218 cases. 

Gradual " " " " 38 " 

Change in the pulse observed in 179 " 

Prostration observed in - 151 " 

External hemorrhage observed in - 148 " 

Retrocession of presenting part observed in - - 146 " 

Abdominal pain observed in ----- - 133 " 

Alteration of countenance observed in 115 ' 

Foetal parts felt immediately under abdominal wall in 77 " 

Acute pain at the moment of rupture observed in - 62 " 

Prognosis.— The great majority of cases end fatally, but Dr. 
J. M. Rose has reported a case wherein uterine rupture took 
place in four successive labors. Death may occur from shock 
or hemorrhage a few minutes after the accident, or maybe post- 
poned for days, or even weeks, and ultimately result from peri- 
tonitis, septicaemia or pyaemia. A loop of intestine may be 
strangulated in the fissure, or be injured in reposition. As will 
be seen in the proper place, laparotomy has saved many lives. 

The statistics collected by Jolly show a maternal mortality 
of about 82 per cent, and a foetal loss of 92 per cent. Aus^ard 
thinks that, under antiseptic precautions and skillful sur- 
gical management, the maternal loss should not exceed 50 
per cent. 

Treatment. — An important part of the treatment is of a 
preventive kind, but this has been sufficiently considered in 
connection with the treatment of the conditions which predipose 
to the accident. 

Treatment of these desperate cases is logically and clearly 
set forth in the following manner by Dr. Charles A. L. Reed, in 
a recent contribution to The New York Medical Journal : 

" Most cases of rupture of the uterus occur in vertex presen- 
tations, and the first objective evidence of the occurrence of the 
accident is recedence of the head. Contraction of the longitu- 
dinal fibers is the next phenomenon, and the head, following the 
direction of least resistance, is forced into the rent. In some 
cases, however, instead of contraction of the longitudinal fibers, 
inertia supervenes, and labor, for the time, comes to a stand- 
still. If, happily, the rent be now incomplete, the timely inertia 



556 Labor. 

arrests the extrusion of the head and saves the peritoneal 
cavity from invasion. It is precisely this latter contingency 
which should dictate the treatment: Apply the forceps and 
deliver at once. 

"The usual alternative of the treatment is turning, as ad- 
vised by Leishman. It is against this alternative that I desire 
to enter my protest. It should be remembered that at this junct- 
ure, as a rule, the differential diagnosis between complete and in- 
complete rupture cannot easily be made. In this case we should 
always act upon the presumption that the rupture is incomplete ; 
and our practice should be adopted with reference to saving the 
peritoneum. In some cases, turning figures as one of the 
primary causes of rupture. Ought we, therefore, in a case in 
which at least partial rupture has already weakened the uterine 
wall, to adopt a manoeuver which has been known to produce 
rupture of the uninjured wall? Clearly the proposition is as 
irrational as the practice is disastrous. 

" But there are instances in which delivery by the forceps per 
vias naturales is impracticable — e. g., cicatricial bands at the 
internal os, and extreme kyphosis. What should be done under 
such circumstances ? I contend that all efforts at delivery by 
any expedient whatever should be at once abandoned. The 
attempt at applying the forceps should not be made if pelvic 
contraction or other insurmountable obstacle to delivery is 
manifest; and if asingleapplicatiouof the forceps demonstrates 
the impracticability of delivery by that method, the verdict 
should be accepted at once. Repeated efforts at applying the 
forceps should be avoided, as each effort will do more or less 
damage to an already damaged uterus, and may thus interfere 
with the resolution of that organ. Turning should not be 
thought of. At this juncture either craniotomy or embryotomy 
has been practiced. The ascertained mortality of the procedure 
but confirms the condemnation which a rational contemplation 
of it furnishes. What, then, should be done? I advise that the 
patient be at once submitted to abdominal section, and delivery 
effected either by incision of the uterus, if the rupture is incom- 
plete ; or through the (if necessary) enlarged rent, if the rup- 
ture is complete ; and that the uterus be then treated according 
to either Sanger's or Porro's method. 

"What shall be done in cases of rupture of the uterus in 
which the child and after-birth have been successfully extracted 
by the natural passage? 



Parturient Anomalies. 557 

"The first thing that ought to be done after successful 
delivery by the natural passage should be to determine, by 
cautious and gentle manipulation, whether or not the case is 
one of complete or incomplete rupture. If found to be incom- 
plete, the case should be treated by antiseptic irrigations. I do 
not employ chemical antisepsis in aseptic surgery, but in this 
case we have to deal with an open and absorbent surface, and, 
very shortly, with the products of putrefaction in contact with 
that surface; hence it becomes eminently proper to employ 
either a phenolic or a mercuric-bichloride solution. 

''But in the event that the tear is found to communicate 
with the peritoneal cavity, we are at once brought face to face 
with one of the moot questions connected with the subject. It 
is just here where Parvin asserts that abdominal section would 
not be justifiable unless 'there has been hemorrhage or escape 
of amniotic fluid into the peritoneal cavity;' and it is pre- 
cisely in these cases that Lusk tells us that 'recovery quoad 
vitam has been obtained by employment of antiseptic irriga- 
tion,' etc., but warns us that this plan of treatment is 'only 
effective where no infection of the abdominal cavity has taken 
place at the time of rupture.' How are we to know whether 
'there has been hemorrhage or escape of amniotic fluid into 
the peritoneal cavity ' ? By what process can we determine 
whether or not ' infection of the abdominal cavity has taken 
place at the time of rupture ' ? Clearly, the only rational re- 
course at our hand is exploratory incision, and I may go a 
step further and say that exploratory incision, in the ordinary 
acceptation of the term, falls far short of the requirements of 
the case. Those of us who are familiar with making the toilet 
of the peritoneum after a bloody ovariotomy know with what 
facility even large clots may elude finest tactile sensibility. It 
is manifest that in cases such as that under discussion nothing 
short of copious flushing can at once establish the diagnosis of 
intraperitoneal extravasation, and rid the cavity of the offend- 
ing stuff. 

"But it is not alone to remove existing infection of the 
peritoneal cavity that abdominal section should be done in 
these cases, but it is to close the rent, and thus prevent, if pos- 
sible, the migration of the germs of putrefaction from the 
cavity of the uterus into that of the peritoneum. It is true that 
this cannot be done in all cases, tears low down in the posterior 
wall being beyond the range of operation ; but, when it can be 



558 Labor. 

done, the edges of the wound should be carefully trimmed, ap- 
proximated, and securely closed by the Czerny-Lembert suture. 

" What shall be done in cases in which the child has been 
born, but in which the placenta has escaped into the peritoneal 
cavity ? 

" This complication occurs with relative frequency, and when 
it does occur it is the next in order of events to claim atten- 
tion. In this class of cases we have a condition in which it 
would seem that removal of the placenta could be readily 
effected through the rent ; but that it is, on the contrary, a very 
difficult manoeuver, is shown in a case which, when I was called 
to it, presented exactly the problem indicated in the question 
at the head of this paragraph. 

"What shall be done in cases in which the child, or the 
placenta, or both, have escaped into the peritoneal cavity? 

"It would seem that the duty of the practitioner is clear 
under these circumstances. Yet, when he turns to our authors, 
he finds himself led in both directions at once. He finds himself 
taught that abdominal section should be done in cases of 
evident contamination of the abdominal cavity; he is told that 
the operation should not be done in all cases in which 'the 
foetus can be readily delivered through the natural passage ; ' 
and he is reminded of recoveries from antiseptic irrigations and 
antiseptic gauze packs ; and then he wonders whether, indeed, 
it be possible to gain direction out of indirection. He is left 
entirely on his own responsibility, and to solve the problem 
strictly on its merits. 

" The first fact to claim attention is that the uterus, in the 
act of rupturing, must have discharged some blood into the 
peritoneal cavity ; and the next is, that the child and placenta 
must have carried with them more or less of detritus. Amni- 
otic fluid may have found its way into the abdomen. These 
considerations alone should prompt abdominal section— if not 
for the purposes of delivery, yet for the purposes of cleanliness. 
If the abdomen is to be opened for the purpose of flushing, 
why not effect delivery through the incision at the same time? 
There are other considerations prompting to this course. The 
advice of Parvin, that abdominal section should not be done 
when the foetus can ■ be readily delivered through the natural 
passage,' is liable to a dangerous interpretation at the hands 
of practitioners who are anxious to evade the responsibilities 
of the knife. With them ' ready delivery ' is liable to imply not 



Parturient Anomalies. 559 

merely the introduction of the hand, which is not devoid of 
danger ; nor the mere grasping of the presenting part, which 
is not always easy ; nor the mere turning in the abdominal 
cavity, which is always hazardous; but a test of the tractile 
power of the operator and the resistant power of the patient. 
In this way patients may be subjected to a hazard which the 
knife in the hands of a skilled operator could not incur. 

"But we are 'informed' that good results have been had in 
some cases by ' washing out the peritoneal cavity through the 
rent with an antiseptic fluid and securing drainage;' and, again, 
we are told of recoveries by ' employment of antiseptic irrigation 
and filling the gap with antiseptic gauze.' I will not dispute the 
fact of such recoveries, for they are well authenticated, but I 
cannot but concur with Harris that every such recovery is to 
be looked upon as a misfortune, tending, as it does, to 
stimulate others to persist in a practice that is essentially 
unscientific. 

"The only danger to life, however, does not come from extra- 
peritoneal infection, which may have found its way into the 
cavity at the time of rupture, or that may have been carried 
thither by the child, or the placenta, or both, nor yet that may 
have subsequently traversed the wound in the form of lochia. 
It must be remembered that the parenchyma of the uterus has 
sustained serious damage (1) by its own violent contractions, 
(2) by the rupture, (3) may be by the use of the forceps, (4) by 
the escape of the child through the tear, (5) by repeated digital 
examinations, (6) by the introduction of the hand, (7) by 
efforts at traction to determine the feasibility of delivery per 
vias naturales, and (8) by the forcible withdrawal of the child 
through the rent. All these influences may have been brought 
to bear upon a uterus before the surgeon is called. What pros- 
pect has such a damaged uterus for resolution? Is it not much 
more liable to become the breeding-ground of septic germs that 
may have originated in the first instance at the placental site? 
And, if we thus have established a suppurative parenchymatous 
metritis, is not the death of the patient from septicaemia almost 
a foregone conclusion? In the light of these considerations 
extirpation of the uterus is clearly indicated, and should be 
recognized as a definite probability in undertaking abdominal 
section in these cases. 

"My conclusions are: 

"First. In cases of rupture of the uterus, with the head pre- 



560 Labor. 

senting, delivery by forceps should be attempted, but should 
be abandoned if not found easily practicable. Turning should 
not be undertaken, but the case should be at once recognized as 
one for either the Csesarean or Porro operation. 

" Second. In cases of ascertained incomplete rupture, treat- 
ment should be by antiseptic irrigations and rest. 

" Third. All cases of ascertained complete rupture should be 
submitted to abdominal section so soon as the condition of the 
patient with reference to shock will admit, for the following pur- 
poses — namely, (1) to explore the abdomen, (2) to remove all 
foreign bodies, (3) to cleanse the peritoneum, (4) to close the 
rent if the labor has been short and the uterus not seriously 
damaged, and (5) to remove the uterus if the labor has been 
long and the uterus seriously damaged." 

The after-treatment of women who have suffered uterine 
laceration, followed by laparotomy, differs in no important 
respects from that bestowed upon laparotomy cases in general. 

Schaeffer, who has given much study to the subject, says 
that laparotomy is most successful in those cases wherein the 
foetus has escaped with intact membranes into the peritoneal 
cavity through the scar of an old Caesarean section or after a 
brief labor. When the foetus, with either ruptured or unrup- 
tured membranes, escapes through a uterine scar during labor, 
the result is favorable in 60 to 77 per cent, of all cases. When 
the foetus escapes, under similar circumstances, during preg- 
nancy, and suppuration results, 60 per cent, recover. When 
rupture of the uterus and complete escape of the foetus into the 
peritoneal cavity, along with the liquor amnii, take place dur- 
ing labor, laparotomy is successful in 44 per cent, of all cases, 
provided no other operation has been previously attempted. 
In those cases where other measures have been tried, and when 
the vesico-uterine pouch has been opened, but 25 per cent, 
recover. When the abdominal viscera protrude through the 
uterine wound, thirty per cent, are saved by operation. Kup- 
ture through the vaginal fornices is peculiarly fatal, only one 
case having recovered. 

Laceration of the Cervix Uteri.— One need but make a 
careful speculum examination of the cervix uteri after labor in 
a consecutive number of cases to become convinced of the great 
frequency of traumatism in this part. The degree of it varies 
greatly, and what appears to be a laceration of considerable 
size w T hen viewed immediately after labor, may be almost oblit- 



Parturient Anomalies. 561 

erated by the time that involution becomes complete. Such 
injuries are relatively more frequent in those instances where 
the labor is instrumentally terminated. 

Lacerations of the Vagina.— Lacerations of the vagina 
occur quite frequently. Indeed, slight ruptures are very com- 
mon accidents, but, as a rule, they give rise to no serious 
symptoms, and hence escape attention. Severe injuries of the 
sort usually come in connection with instrumental delivery. If 
the rupture is deep enough to include the entire thickness of the 
septum, anteriorly or posteriorly, the passage of urine or faeces 
is likely to prevent repair, and thus a vesico-vaginal or recto- 
vaginal fistula may result. 

But fistulae more frequently proceed from long-continued 
compression of the pelvic tissues by delay of the foetal head in 
the pelvic cavity. In such cases the soft structures become 
devitalized, and, as a consequence, a slough comes away within 
the first few days succeeding delivery, followed by the evidences 
of fistula. 

Treatment. — Lacerations of the vagina ought at once to be 
repaired in the manner described in chapter 3, Part III. The 
results of these operations are almost uniformly successful. 

Kents involving both cervix and vagina cannot be so easily 
managed, and should usually be treated on the expectant plan. 

In suturing lacerations extending entirely through the sep- 
tum anteriorly or posteriorly the needle should not penetrate 
the mucous surfaces of the organs thus opened. 
(36) 



562 Labor. 



CHAPTER XVI. 

PARTURIENT ANOMALIES ARISING IN THE THIRD STAGE 

OF LABOR. 

Post-partum Hemorrhage— Floodings after delivery pre- 
sent a variety of symptoms, and, hence, may be divided, accord- 
ing to their manifestations, into several classes. Thus we have: 

1. External hemorrhage. 

2. Concealed, or internal, hemorrhage. 

3. Primary hemorrhage. 

4. Secondary hemorrhage. 

5. Hemorrhage of various degrees, namely, first degree, 
second degree, third degree. 

1. When the flow meets with no restraint, but passes the 
vulva, sometimes in sparing quantities, again in alarming 
gushes, it constitutes external hemorrhage. 

2. When, owing to some obstacle encountered at the cervix, 
the blood which flows from the uterine vessels is held in utero, 
we term it concealed hemorrhage. 

In the same category may also be included that form of 
bleeding which escapes fche attention of those under whose care 
the woman has been placed, until a considerable pool has 
formed in the center of the bed. Such flooding is sometimes, 
but should never be, unrecognized, even though it be out of im- 
mediate view. 

3. When bleeding in any considerable quantity occurs within 
the first two or three hours after labor, it is regarded as 
primary. 

4. When postponed until a later period, it is properly 
secondary. 

5. Hemorrhage of the first degree is that wherein but little 
blood is lost, though for a moment it may flow in a stream. 
This occurs in perhaps 10 per cent, of all labors. 

Hemorrhage of the second degree is that which comes in 
profuse gushes, and does not yield at once to abdominal pressure, 
but requires other measures for its arrest, and even afterwards 
manifests a disposition to return. 

Hemorrhage of the third degree includes dangerous bleed- 
ings, wherein the loss is excessive, and the prostration profound. 

The Causes of post-partum hemorrhage are various, and, 



Parturient Anomalies. 563 

inasmuch as they constitute an indispensable basis for intelli- 
gent treatment, they require thorough study. 

Among the indirect or predisposing causes we may mention 
precipitate labor. It is not altogether clear why a uterus 
which has expended but a part of its nervous energy in expul- 
sive effort should become atonic, and bleed profusely, as soon 
as labor is brought to a close, and yet clinical experience teaches 
that it often does. Very likely the effect is produced by tem- 
porary exhaustion, arising from the intensity of the labor w T hile 
it lasts, muscular inertia following here as it does elsewhere, 
upon the heels of violent exertion. Contractions may be re- 
markably powerful, and the vital force escape exhaustion pro- 
vided the action is not too long-continued. In rapid labor 
there is often scarcely any intermission between the pains, and 
occasionally but slight remission, as the result of which ex- 
haustion may overtake the uterus before parturition has lasted 
two hours. 

Following unduly -prolonged labor we sometimes get a simi- 
lar condition. Contractions having been forcible, but inter- 
mittent, action is well sustained for a long time ; but want of 
relative proportion between the foetus and the pelvis, or the 
existence of some mechanical obstacle, may prolong the process 
to so great length that inertia finally results. The uterine mus- 
cles, like those of other parts, must, after long and vehement 
effort, have a prolonged period of rest. Labor being completed, 
and the stimulus by w 7 hich the uterus has been provoked to 
action removed, the organ falls into atony at what proves to 
be an unfavorable moment, and is not easily aroused to re- 
newed activity. Labor, then, which presents either of these ex- 
tremes, should be regarded as a predisposing cause of post- 
partum hemorrhage. 

Besides the direct hemorrhage resulting from cervical lacera- 
tion involving an artery, there is no doubt that a plain tear is 
occasionally productive of uterine relaxation and consequent 
hemorrhage; but this action is probably not so pronounced 
with respect to the primary, as to the secondary, form of post- 
partum bleeding. It was long ago showm by Emmet and 
others, that proper involution of the uterus after labor is em- 
barrassed or prevented by cervical fissure. The uterine cavity 
being accordingly more capacious than normal, exciting causes 
combine to bring about congestion of the organ and conse- 
quent blood-loss. 



564 Labor. 

Flaccidity of the uterus after labor, and the bleeding result- 
ing from it, are, doubtless, often the consequence of slovenly 
practices, — a neglect of those details which should be matters 
of routine in every case. Delivery is suffered to take place while 
the bladder is distended with urine ; the extended head is per- 
mitted to obstruct parturition for an indefinite time without 
any attempt at rectification ; the practice which nearly all con- 
cur in commending for every case, namely, pressure on the 
fundus uteri during and after fcetal expulsion, is totally disre- 
garded ; or the placenta is prematurely extracted. 

Constitutional dyscrasise account for a small percentage of 
cases. There is what has been termed the "hemorrhagic diathe- 
sis," or hemophilia, which strongly predisposes to flooding. 
This is generally understood to depend on an abnormal condi- 
tion of the circulating fluid, which favors its escape from the 
blood-vessels, whether ruptured or not. There is a condition 
closely allied to this, wherein post-partum bleeding depends, 
not so much on an abnormal state of the blood itself, as 
upon constitutional predisposition to lax muscular tone. Such 
women have been termed "bleeders," inasmuch as, though 
sometimes apparently well nourished and vigorous, they suffer 
from floodings in repeated confinements to the extent of pro- 
ducing syncope and profound exhaustion. 

Repeated child-bearing predisposes to the accident. It rarely 
occurs after first labors. 

The proximate causes are first, and most frequently, uterine 
atony, flaccidity, inertia. 

In general, we find after expulsion of the foetus and placenta, 
the uterus contracting into a globular-shaped mass which is 
felt in the hypogastrium, and which, from its firmness and form, 
has been termed the cannon-ball contraction. Such firm con- 
densation compresses the large blood-vessels of the organ, 
thereby effectually preventing loss, and rapidly hastening per- 
manent involution. It is clear that this favorable state is 
brought about by the muscular tone which the organ still 
maintains, despite the severe strain to which it has been sub- 
jected. When, from any cause, this firm condensation of the 
blood-loaded organ fails to take place, the gaping vessels, at 
the site of placental attachment, encounter nothing to restrain 
a free escape of the warm life-fluid which they contain. 

Probably 98 per cent, of all cases of post-partum hemor- 
rhage owe their immediate origin to this condition of the 



Parturient Anomalies. 565 

uterus, and hence it ought never to be out of mind in the con- 
duct of labor. 

There sometimes exist obstacles to proper contraction of 
the womb after it is delivered of the product of conception. A 
large accumulation of urine may interfere materially, not only 
by direct encroachment upon the space afforded the pelvic 
organs, but also by sympathetic effect. Attention to the blad- 
der during and after labor is a matter which young practi- 
tioners, before they have acquired routine habits, are extremely 
prone to neglect. 

Tumors, generally fibroid, may thicken the walls or encroach 
on the cavity of the uterus, thereby preventing a complete, 
safe and equable condensation of the organ, and, by this con- 
dition, exposing the woman to serious depletion. 

In certain instances there is hemorrhage escaping the vulva, 
not very profusely at any time, but continuously, though the 
uterus be firmly contracted. Failing to subdue it by ordinary 
means, we learn from a careful examination that it proceeds 
from a laceration of tissue involving a blood-vessel. The cir- 
cular artery of the cervix is sometimes ruptured during passage 
of the foetus, giving rise to a moderately free sanguineous 
flow. 

The vestibule, which suffers a solution of continuity oftener 
than is generally supposed, occasionally bleeds profusely from 
its lacerated surfaces. 

Premonitory Symptoms. — Post-partum hemorrhage some- 
times gives notice of its approach, but the signs are so ambigu- 
ous that little importance can be attached to them. Short, 
sharp pains, followed by complete uterine relaxation, are said 
often to presage the ill occurrence. 

Some light is shed on the probabilities by a study of the 
woman's history, and by observation of her bodily habit. If 
she gives an account of previous bleedings, whether post- 
partum or other; of habitually profuse menstruation; and, 
finally, if the tissues of the body evidently lack healthy tone, 
we have reason to fear hemorrhage. 

A rapid pulse is commonly regarded as a highly suspicious 
symptom, and, so long as it continues, the woman is thought 
to be in imminent danger of the accident which we are now 
studying. Dr. J. Ashburton Thompson has made extensive 
and minute observations, and as a result thereof has been led 
to believe that " these notes justify a contradiction of the bare 



566 Labor. 

assertion that a pulse which beats at or about a hundred shortly 
after labor prognosticates inertia of the uterus. * * * These 
notes show that in fact I have disregarded the pulse-rate as a 
prognostic, or indication, of my patient's safety from hemor- 
rhage." Dr. M. M. Bradley found in 300 cases that the pulse was 
from 50 to 130. "From these observations," he says, "I am 
not inclined to attach much importance to the pulse-rate, either 
as a sign of danger, or of post-part urn hemorrhage." 

The degree of blood-pressure has some influence to produce 
and maintain hemorrhage from the uterus after labor, and it i» 
a physiological fact that with high arterial tension we most 
frequently have a pulse of but moderate rapidity. 

General Symptoms. — Hemorrhage usually sets in soon after 
expulsion or extraction of the placenta, and nearly always within 
the forty-five minutes immediately succeeding. Occasionally 
it begins when yet the secundines remain undelivered, while the 
attendant is giving the child necessary attention. 

If the hand rests upon the fundus uteri, as it ought in every 
case at this stage of delivery, contraction, which at first may 
have been good, is observed to relax, and the womb, which w T a& 
easily felt while in a condensed form, now escapes, so that its 
outline cannot be clearly defined. 

Bleeding generally begins suddenly, and often ceases in the 
same manner. There may be but a single gush, or one spurt 
may succeed another, and rapidly reduce the woman. Some- 
times the flow is comparatively passive, but exceedingly per- 
sistent, so that in half an hour there is great depletion. In 
bad cases the blood runs in a torrent, and rapidly drains the 
system. 

In concealed hemorrhage, though the womb, after delivery, is 
at first firmly contracted, it soon becomes flaccid; an impedi- 
ment, frequently in the form of acoagulum, obstructs the flow; 
the uterus offers but feeble resistance, and bleeding goes on 
within. In case the hand is kept properly applied to the abdo- 
men, and a clear uterine outline insisted upon, there is little 
likelihood of dangerous blood-loss. Bad examples of hemor- 
rhage are met in those cases wherein abdominal pressure is 
neglected, or the bleeding begins a considerable time after 
labor, when watchful care has ceased. There being no out- 
ward indication of the flow, its occurrence is not often recog- 
nized until the effects of depletion are manifested in the 
countenance and feelings of the woman. She will complain 



Parturient Anomalies. 567 

of great exhaustion, and may fall into a state of syncope. 
Alarmed at her condition, the physician feels her wrist only to 
find the pulse feeble and fluttering, or finds it not at all. The 
hand on the abdomen obtains clear evidence of a distended 
uterus, and firm pressure causes the coagula to gurgle forth 
into the bed. 

There is a spurious form of concealed hemorrhage that is 
manifested as a result of professional ignorance or inattention. 
The ordinary precautions are disregarded— the fundus uteri is 
left uncovered by the hand, none of the signs of bleeding are 
watched for, and the accident is far advanced before the guilty 
attendant is aware of its existence. Blood pours forth noise- 
lessly, w T hile the patient, reposing the utmost confidence in the 
skill of her physician, rests quietly, until she feels a deathly 
sensation stealing over her and is impelled to call for help. 
On throwing up the bed-clothes there is found, to the conster- 
nation and shame of her dull attendant, a great pool of blood. 

The symptoms of post-partum hemorrhage differ mainly in 
intensity. There may be but a brief flow, producing no special 
effect on the woman. This is the sort which the young practi- 
tioner so often meets, and which responds readily to a dose of 
ipecac or belladonna, given in a routine way. In other in- 
stances, happily infrequent, the flow begins like the other, is a 
little more free, and is indisposed to surrender to the remedies 
mentioned, or to any other drug, but ultimately ceases, either 
from natural causes, or manual treatment combined with re- 
frigeration. In a third class of cases, the flow comes suddenly, 
and spurts from the vulva like water from a pump, waits for 
nobody, is unmindful of drugs, yields to neither cold nor heat, 
and, in the absence of proper treatment, hurries the patient 
down through the various stages of loss. The extremities 
become cold and damp; the countenance gets pale and ghastly ; 
the pulse rapid and small — perhaps intermittent; the limbs 
weary but restless. There is sighing respiration, dimness of 
vision, and syncope. Later the whole body, and even the 
breath, grows cool ; intense restlessness and jactitation super- 
vene ; and death ends the scene. 

Secondary Hemorrhage, after labor at full term, is generally 
consecutive upon other symptoms which indicate a retention in 
utero of a fragment of the secundines, or a coagulum; the 
existence of interrupted involution, or of malposition of the 
organ. 



568 Labor. 

When the placenta is delivered in any case of labor, it ought 
to be carefully inspected to make sure that no part is left 
behind. If much traction force is applied to the cord, the bulk 
of the organ and membranes may be brought away, while a 
portion, large or small, is left behind. Disintegration of such a 
fragment usually takes place, and the detritus passes off in the 
lochia, without disturbance; but in other cases, hemorrhage 
results. 

There is developed in rare instances a supplementary pla- 
centa, placenta succenturia. The connection between the 
organs being marginal, the smaller, or secondary one, may be 
left behind. Any examination but the most minute would 
scarcely be sufficient to disclose the fact, and it comes to light 
only when hemorrhage, or septic symptoms, with offensive 
discharges, lead to uterine exploration. 

In few cases of secondary hemorrhage do we find the flow 
extremely profuse. It is alarming on account of the period 
when it occurs, the time for flooding presumably being past. 
Still, the patient occasionally evinces signs of great depletion, 
and may threaten collapse. 

During the first few days after delivery, even in normal cases, 
the woman is in a state favorable to the development of a 
variety of ills, and, among them, sudden and profuse blood-loss. 
A powerful disturbance of the emotional nature exhibited in 
great joy, anger, or fear, is capable of giving rise to serious, 
even fatal, hemorrhage. Instances of the kind have been placed 
on record, which stand as serious reminders of possible 
occurrences. 

Prognosis. — The remote effects of excessive loss, some of 
which have been mentioned in another chapter, should not be 
forgotten. A train of ills is liable to follow, and make misera- 
ble an otherwise happy life. The immediate prognosis in most 
cases is favorable. The great majority of women do well after 
flooding, and some authorities have accordingly taught that it 
is more alarming than dangerous. There are always entailed a 
few days of suffering from headache, prostration, and, may be, 
vomiting and purging. Then follow convalescence, and, in 
favorable cases, perfect restoration. But the exceptions occa- 
sionally observed, in respect to both immediate and remote 
effects, should give to the favorable prognosis an air of 
seriousness. 

Women who have suffered a considerable loss of vital fluid 



Parturient Anomalies. 569 

are much more liable to septic infection. The system seems 
ready to drink in whatever is offered, whether nocuous or in- 
nocuous, as does an empty sponge. In such cases, there is 
the greater need of thorough cleanliness in the management 
of the case. 

Treatment.— Pre ventive treatment is of the utmost conse- 
quence, and yet it consists in the adoption of but few special 
rules. The directions given for the conduct of normal labor are 
generally sufficient of themselves, when scrupulously observed, 
to prevent the occurrence of untoward symptoms after deliv- 
ery. If we make it a rule of practice attentively to observe the 
progress of the head through the pelvic cavity, and see that it 
follows those positions and movements which are favorable to 
ready performance of the mechanism of labor, which in their 
turn preserve the uterus from undue exertion ; if we keep the 
bladder empty; if, upon expulsion of the child, we apply an 
assistant's hand to the contracting uterus, and keep it there, 
not only till the close of the third stage, but for a considerable 
time thereafter; if, finalty, we combine Crede's method of pla- 
cental delivery, with slight traction, if necessary, on the cord, 
we will rarely indeed have thrust upon us a severe case of hem- 
orrhage. Crede's method of placental delivery commends 
itself, with much emphasis, to our adoption.* 

Occasionally we feel called upon to adopt more specific treat- 
ment for the prevention of impending danger. The woman 
perhaps is a " bleeder," and gives a history of a previous flood- 
ing of a most violent type; or, it may be, without any such 
history, the uterus, from exhaustion of its overworked powers, 
towards the close of the propulsive stage manifests unmistak- 
able symptoms of inertia. In either case, ordinary routine 
treatment may prove inadequate to avert the threatened 
accident. In such occasional instances justice to our patients 
demands that we bring to bear forces better able to meet and 
temper the crisis. The pathological condition of the uterus 
which we fear will be developed as soon as that organ has been 
emptied, is flaccidity of its walls, which condition affords free 
escape to the blood circulating within. Now, if there is any 

* We may judge of the improvement effected by the introduction of Crede's plan of 
treatment from the statistics of Bossi (Wiener Medicinische Wochenschrift, Nos. 30-32, 
1863), who says that, in the clinical wards at Vienna, where the new method was in every 
instance adopted, the cases of post-partum hemorrhage amounted only to 1.47 per cent., 
while in the other wards, where the old line of practice was followed, they amounted to 
3.52 per cent. 



570 Labor. 

remedy which is capable of stimulating contraction, without at 
the same time seriously harming the patient, in the name of 
humanity it ought to be given. Ergot of rye is capable of doing 
this very thing in the great majority of cases ; but to get the 
effect, it must be administered in appreciable quantities. A 
single dose of one drachm of the fluid extract (Squibb's pre- 
ferred) may be given by the mouth, or ten drops of the same 
may be injected deeply into the tissues. The latter mode of 
administration is to be preferred, as when so employed the drug 
acts with greater celerity, certainty and energy. 

The time to administer ergot as a preventive of post- 
partum hemorrhage is when the head lies at the pelvic outlet. 
Delivery may be effected by the forceps, or by the natural 
efforts, and the placenta subsequently removed. By the time 
this is done the drug will have produced its effect in the form of 
firm uterine contraction. 

Nevertheless, be it remembered that we consider cases of this 
kind rare at the most, and rarer still among those who have 
been under wise homeopathic treatment for a time preceding 
labor. We should also say for the encouragement of those true 
apostles of Hahnemann who regard the law under which we 
practice as universal in its application, that we have never 
met a case which, in our opinion, required such treatment as we 
have described, and none which, notwithstanding unfavorable 
histories of former labors, failed to pass the critical post- 
partum period without serious blood-loss. At the same time, 
in specially unpromising cases*we should suffer no impugnings 
of conscience in following the line of treatment before indicated. 

Dr. McClintock advocates rupture of the membranes. "I 
have adopted the precaution of rupturing the membranes," he 
says, " on very many occasions, and am fully persuaded it is a 
most valuable, and always a feasible, auxiliary in the prevention 
of flooding after delivery." Dr. Dewees accounted it the prin- 
cipal means to be relied on for the purpose of averting the 
accident. 

Preservation of the membranes till after entrance on the 
second stage of labor is most emphatically enjoined by some 
excellent obstetricians as an important factor in the prevention 
of post-partum hemorrhage ; but in our own practice we have 
not given it the slightest heed. 

The following hints on the prophylaxis of post-partum 
hemorrhage, by Dr. Pry or, we shall do well to remember: "It 



Parturient Anomalies. 571 

is not at all infrequent," he says, "that we are called to attend 
women who have had hemorrhage following their previous con- 
finements, and who look forward to the close of gestation with 
fear and trembling, the predisposing causes of hemorrhage 
during pregnancy and parturition being intensified by the 
hemorrhagic diathesis. By gaining their entire confidence with 
the assurance that we possess means of prevention almost in- 
fallible, we gain an advantage of no little value as a means of 
prophylaxis. Take a case where you have reason to apprehend, 
or where hemorrhage has actually set in : apply a ligature or 
bandage (about an inch in width) around each extremity, as 
close to the body as possible, drawing them sufficiently tight to 
arrest the return of venous blood without materially affecting 
the arterial circulation, then proceed with your other mechani- 
cal as well as medicinal agents.'' Dr. Pry or puts great confi- 
dence in this mode of treatment. 

In addition to these means, it is advisable immediately to 
apply the child to the breast. The close sympathy between the 
breasts and the uterus gives significance to the act. 

The room occupied by the patient should be free from a 
company of noisy, excited women. Let everything be done 
decently and in order, without confusion or agitation. The 
physician, above all, in such an emergenc}^, should keep his 
emotional nature in perfect subjection. He must not stop 
to ponder possibilities or probabilities, or to reflect upon his 
immense responsibilities, for these will be patent enough. He is 
the presiding genius, and the result largely depends on his 
executive ability. 

Treatment of Hemorrhage of the First Degree. — Under fear, 
or excitement, the young practitioner is liable to adopt too 
vehement practices for the arrest of hemorrhages of the first 
degree. It should be remembered that the last stage of labor 
is always accompanied with more or less blood-loss, and if not 
remarkably profuse or prolonged, it need excite no alarm. To 
apply ice and snow to the abdomen, or carry it into the vagina ; 
to dash cold water over the abdomen, or to pass the hand 
into the womb for the purpose of checking such a flow, is not 
only unnecessary, but positively reprehensible. In such cases 
the fundus uteri should be pressed firmly with the palm of the 
hand, made cold, if necessary, by dipping in cold water, and in 
a moment the flow will cease. We should not neglect this 
procedure for the purpose of administering a remedy, however 



572 



Labor. 



well indicated. The most effective treatment of a simple sort 
must be adopted, or a slight loss may be transformed into a 
profuse hemorrhage. The womb in such cases seems a little 
undecided between contraction and expansion, and requires 
but a suggestion to fix its choice. 

In this same class we may properly include that variety of 
hemorrhage which depends on a laceration of the cervix or ves- 
tibule. The flow is not profuse, but is persistent; and firm 
contraction of the uterus is observed to have little effect on it. 
The bleeding vessel is effectually controlled by suturing the rent 
with catgut, in order to do which, when the torn vessels are in 
the cervix, the uterus must be drawn down to the vulva. 




Fig. 255. — Bimanual compression of the Uterus. (After Breisky.) 

When for any reason the laceration cannot be thus repaired, 
and the hemorrhage effectually controlled, a vaginal douche at 
a temperature of 120° F. may be given. Other treatment will 
rarely be required. 

Vestibular bleeding should be controlled in the same manner. 

Treatment of Hemorrhage of the Second Degree. — This con- 
sists of manual compression, cold applications, hot vaginal 
douche, indicated remedies. 

First of all, we should compress the uterus and hold it. 
To do this one hand grasps the organ as felt in the hypogas- 
trium, while the fingers of the other are passed into the vagina, 
and the uterus is well compressed between them. While thus 
firmly held, the vessels cannot bleed profusely, and in a few 
minutes the internal hand may usually be removed without a 



Parturient Anomalies. 573 

recurrence of the flooding. A few doses of the indicated remedy 
ought to be administered, and the womb held for a few minutes 
with the abdominal hand, when farther treatment will be 
unnecessary. 

Should there be a return of the flow after removal of the 
vaginal hand, both hands may be dipped into cold water and 
replaced. Should this fail to control the flow, the patient must 
have a vaginal douche with the water at a temperature of 118° 
to 120° F. Or, what is still more effective, the syringe tube 
may be carried well into the uterine cavity and the water 
thrown directly against the fundus uteri. In doing this, neither 
the uterus nor vagina should be so blocked as to prevent free 
exit of the return flow. 

There can be no reasonable doubt of the efficacy of the 
closely affiliated remedy in regulating the disturbed vital action, 
and thereby subduing post-partum hemorrhage; but in view of 
the extreme liability to error in our choice of remedies, and the 
certainty with which other measures can be employed, the 
latter should first be applied, and then reinforced by the former. 

Treatment of Hemorrhage of the Third Degree. — Through 
mismanagement, hemorrhage of the second degree may ex- 
ceed its bounds and merge into that of the third. Treatment 
of these appalling cases consists in manual compression, cold 
applications, hot intra-uterine douches, indicated remedies, 
electricity, styptic injections, aortic compression. 

Firm pressure of the uterus between the hands, as described, 
must not be neglected, for it is fche most important part of 
treatment. To neglect it here would be as absurd as, in surgery. 
to neglect to take up a cut artery, while various applications 
and remedies by the mouth are resorted to in the vain hope 
that they may prove effectual in staunching the flow of blood. 

The relaxed state of the uterus is many times dependent on 
the existence in utero of coagula, and firm condensation cannot 
be acquired and maintained until they are removed. Accord- 
ingly it is set down as one of the most important principles of 
treatment, thoroughly to evacuate the uterus. 

Cold water may be used as before indicated, or, instead of ifc, 
ice may be applied to the abdomen and introduced through the 
vulva, or, if thought requisite, even into the uterine cavity. 
Some have recommended pouring cold water from a height on 
the abdomen, but the advisability of so doing is questionable, 
save in the case of warm, vigorous women. Much harm may 



574 Labor. 

be done by an injudicious use of cold. Let it be remembered 
that refrigerants derive their efficacy mainly from the first im- 
pression which they make, and long continuance of them is 
unwise. 

The other extreme of temperature is still more fruitful of 
good results. Applied to the lumbo-sacral region, hemorrhage 
from the womb is sometimes speedily arrested by it. We have 
found hot water a most efficient means for controlling uterine 
hemorrhage, when injected directly into the uterine cavity. 
There is little or no danger connected with the operation, pro- 
vided there be no obstacle to free escape of the injected fluid. 
Immediately after labor the os uteri is so wide tljat the water 
can easily flow away, and the uterus at such a time will safely 
tolerate thorough irrigation. When the operation is under- 
taken, the nozzle of a fountain syringe should be passed 
through the os uteri to the fundus, against which the stream 
will be directed. 

" One of the essentials to a safe administration of an intra- 
uterine injection," we say in a recent article on The Use of Hot 
Water in Obstetrical Practice, " is a good syringe. I have used 
the 'bulb' syringe, but greatly prefer the 'fountain/ or some 
other instrument which acts on the siphon principle. The 
syringe should be either new or thoroughly clean and aseptic. 
If my choice were between an old syringe, the cleanliness of 
which could not be guaranteed, and the administering of no 
injection, I would say, 'I will withhold the syringe and rely for 
help on other measures.' 

"The water should be hot, as hot as can be borne, namely, 
115° to 122° F. temperature; when of a lower temperature it 
does little good. The tube ought to be carried nearly to the 
fundus uteri and the stream given but moderate force. The 
quantity of water will be regulated by circumstances. In one 
case two gills may answer, while in another a gallon may be 
required. We commonly get prompt effects ; but now and then 
relief comes slowly. 

"Very hot water produces its hemostatic effects in uterine 
hemorrhage not alone by local action, but also by virtue of 
reflex excitement. The primary effect on the blood-vessels is 
contraction, and hence the prompt response usually obtained. 
The flow of blood ceases almost as soon as the stream of 
water strikes the fundus uteri, towards which it should be di- 
rected. The calibre of both large and small vessels is at once 



Parturient Anomalies. 575 

diminished, thereby greatly reducing the loss and bringing 
it within normal limits. 

" While this is the result usually obtained, doubtless it would 
be but temporary were not other and permanent action at the 
same time, and by the same means, brought about. Not only 
are the blood-vessels greatly diminished in their carrying 
capacity by contraction of their circular fibers, but, through 
reflex action, forcible contraction of the whole bleeding organ 
is excited, and the alleviation thus rendered permanent." 

Ergot has been recommended as a remedy for all forms of 
dangerous uterine hemorrhage, and yet there appears to be 
little place for it here. Hemorrhage of the third degree 
generally runs its course too rapidly for us to expect much aid 
from the remedy, especially when administered through the 
mouth, and the other degrees of hemorrhage do not require it. 

Despite the treatment above recommended, flooding may 
continue, or be no more than temporarily subdued, and for such 
cases we have further expedients which have many times availed 
to save life. Styptic intra-uterine injections of various sub- 
stances have been recommended, but that which has afforded 
the best aid is the perchloride of iron. One of the strongest 
advocates of such treatment is Dr. Robert Barnes, and we 
append his formula and mode of application. "Solid ferric 
chloride 1 ounce, dissolved in 10 ounces of water, or the liquor 
ferri perchloridi (Br. Ph.) 1% ounces, water 7% drachms. The 
rules in using it are: (1) be sure that the uterus is empty of 
placenta, blood, and clots; (2) compress the body of the uterus 
by the hand during the injection ; (3) have two basins at hand, 
one containing hot water, the other the ferric solution ; pump 
water well through the syringe — a good Pligginson's will do — 
so as to expel air ; then pass the uterine tube into the uterus, 
and inject first hot water, so as to wash out the cavity and 
give a last opportunity for evoking diastaltic contraction ; then 
shift the receiving end of the syringe into the ferric solution, 
and slowly, gently inject about seven or eight ounces, carefully 
keeping up steady pressure on the uterus throughout and 
afterwards." 

Intra-uterine injections of vinegar have been used with good 
effect, while a strong solution of alum has been equally effica- 
cious. 

In desperate cases, compression of the abdominal aorta has 
served to arrest the flow. This can be done through the ab- 



576 Labor. 

dominal walls, the vessel being easily felt pulsating on the left 
side of the spine. It may also be done in a thoroughly relaxed 
uterus by the hand which is slipped into the cavity of the 
organ ; but we should advise against the method. Long-con- 
tinued compression is unwise, but a brief arrest of the hemor- 
rhage will give time for coagulation of blood in the bleeding 
vessels, which may serve permanently to arrest the flow. 

Electricity. — The Faradic current has a powerful effect upon 
the uterine muscular fibers, inducing firm contraction. A 
battery is rarely at hand, but when one is to be had at the 
critical moment, its aid should be invoked. The operator's 
hand makes a fair, though not a very comfortable, in tra-uterine 
electrode, but the current is quite as effective when one electrode 
is applied to the sacrum, and the other to the hypogastrium. 
A metal, or carbon, intra-uterine electrode would, of course, be 
far preferable. 

The caution elsewhere given may be repeated here :— the phy- 
sician must beware how he interferes in those cases where the 
loss has been excessive, but has temporarily ceased. Tt is the 
last ounce of blood that kills. It may be that syncope has en- 
sued, and the feeble circulation which characterizes the condition 
has led to the formation of coagula. To excite the circulation, 
or to interfere with the clots, may awaken renewed flooding. 
Therefore withhold the hand, and attentively watch the case. 
Renewed strength, or renewed hemorrhage, will indicate the 
moment for interference. The woman rallying sufficiently to 
bear the strain, we may empty the uterus and stimulate per- 
manent contraction. The hemorrhage returning, we may take 
like action effectually to arrest it. Therefore, when there is 
syncope, we should not hastily begin stimulation, but guard 
against complete cardiac failure. Should dangerous symptoms 
ensue, stimulate well. For this purpose the hypodermic admin- 
istration of sulphuric ether and of glonoine has proved 
efficacious. 

Tamponing the uterus with iodoform gauze has been prac- 
ticed to a limited extent, but we cannot yet look upon it with 
approval. 

Transfusion. — When the first edition of this work was pub- 
lished, we hoped that transfusion of blood for the relief of 
profound anaemia after flooding would soon prove successful in 
practice; but nothing encouraging has thus far been accom- 
plished. 



Parturient Anomalies. 577 

The subcutaneous injection of a solution of chloride of 
sodium has been practiced with some success, and, when care- 
fully performed, doubtless helps to supply the hungry vessels 
with a circulating fluid so as to prevent absolute collapse. The 
solution should be of a strength of 6 parts to 1,000, the points 
of injection are the subclavicular and inter-scapular regions, 
and the quantity introduced, from six to thirty ounces. It is 
given by means of a glass funnel with rubber tube and a fine 
needle. The solution must be of a temperature of 100° F., 
and it is carried into the tissues by the mere weight of the 
column of fluid. 

The Treatment for Concealed Hemorrhage, Post-partum, 
differs in no material respects from that already given for ex- 
ternal bleeding. As soon as the condition is recognized, the 
distended uterus is to be compressed with the hand from above, 
and the discharge of its contents enforced. The hand should 
then be introduced, and all retained coagula removed. 

Secondary Hemorrhage requires the application of similar 
principles of treatment, it being quite essential that the womb 
be well emptied. This form of flow, depending, as it does in 
many cases, on retained parts of placenta, will generally re- 
quire introduction of the hand, though if manifested at a con- 
siderable interval after labor, the fingers alone will answer. 
After removing a retained fragment it is well to wash out the 
uterine cavity with a hot antiseptic douche. 

For the sub-involution existing in such cases, secale cornutum 
is probably the best remedy. Trillium or trillin is nearly as ef- 
ficacious. Other remedies may be indicated by special symptoms. 

The following summary of treatment for post-partum hem- 
orrhage may be found convenient : 

Preventive Treatment.— Observe the rules for the conduct 
of normal labor. 

Administer indicated remedies. 

Give ergot by the mouth, or by hypodermic injection, just 
before the close of the second stage of labor, in extremely 
threatening cases. Do not remove the placenta too soon. If 
not naturally expelled, combine expression with extraction for 
its delivery. 

Apply the child to the breast. 

Curative.— General.— Lower the head and elevate the hips. 

Have the room quiet. 

Be calm and self-collected. 
(37) 



578 Labor. 

Primary Hemorrhage— 1st Degree.— Press on fundus uteri 
with cold hand. 

Avoid vehement practices. 

Administer indicated remedy. 

Suture torn cervix or vulva when torn vessels bleed. 

2d Degree.— Compress the uterus between the hands and 
empty it. 

Use cold applications. 

Use hot vaginal, or intra-uterine, douche. 

Give indicated remedies. 

3d Degree. — Compress the uterus between the hands, and 
empty it. 

Use cold applications, — ice, if necessary. 

Use hot intra-uterine douche. 

Give indicated remedies. 

Use electricity. 

Styptic injections. 

Aortic compression. 

Secondary Hemorrhage.— Empty uterus and treat as other 
forms. 



Parturient AnomalieSo 579 



CHAPTER XVII. 



PARTURIENT ANOMALIES ARISING IN THE THIRD STAGE OF 

LABOR — Continued. 

Retained Placenta.— In practice we have found this term 
of variable significance. Especially is this true in consultation 
practice where one has an opportunity to examine the different 
cases wherein this is said to be a complication. It resolves 
itself into this, namely, what one accoucheur regards an ex- 
ample of true retention, another may discover to be only an 
instance of little more than ordinary difficulty. Through mis- 
application of the principles of placenta delivery, or from want 
of due energy in the application of them, the placenta may be- 
come practically retained. Without reference to efforts at 
delivery such as we have recommended as appropriate to every 
case, mere traction is sometimes made with the effect to invert 
the placenta and bring it to the os uteri in such a way as to 
prevent entrance of atmospheric air, and make the retentive 
powers of the uterus extremely difficult to overcome. In exer- 
cising pressure, the uterus, instead of being crowded downwards 
towards the pelvic cavity with the hand grasping the fundus, 
is merely flattened from before backwards, or from the opposite 
direction. In a number of instances when we have been called 
to deliver what was said to be a retained placenta, we have 
found it in the vagina, only awaiting easy removal. 

When Crede introduced his method of placental delivery he 
declared that "the spectre of adherent placenta would be scared 
away." True placental retention from any cause, after labor, 
at or near term, we regard as extremely rare. 

There are three causes of retention : 

Irregular uterine contraction; abnormal adhesions, due in 
most instances to former endometritis; want of firm uterine 
contraction. 

Treatment. — When the placenta cannot be gotten away by 
firm pressure of the uterus, coupled with judicious traction on 
the cord, within what may be regarded as a reasonable time, 
other measures must be employed, for long retention is a 
dangerous complication. 

No hard and fast rule should be laid down for our guidance 
concerning the time for manual delivery of the placenta. Each 



580 



Labor. 



case must be decided on its own merits. The " reasonable time" 
of which we have spoken may in one instance be only thirty 
minutes, while in another it may be two hours. 

Before resorting to artificial separation and extraction, we 
should for a time try the effect of remedies, fitly chosen, and 
meanwhile keep the case under attentive surveillance. 

If the retention is not overcome by these measures within an 
hour, we believe it is wise, in the absence of contra-indicating 
symptoms, to pass the hand partially or wholly into the uterine 
cavity for the purpose of removing the after-birth. A digital 
examination will indicate the advisable course to follow. The 
four fingers may be entered, if necessary, and if a border of the 
placenta can be reached, it should be drawn 
down, when, if no morbid adhesions exist 
between that organ and the uterus, compres- 
sion of the latter and slight traction on the 
cord will suffice to secure delivery 

Injection of the umbilical cord to its full 
capacity is said sometimes to arouse the 
uterus to contraction, and thereby bring 
about separation of the placenta; but we 
have never tried it. 

If such efforts fail, the fingers may be 
pushed onwards into the uterine cavity, and 
separation undertaken. By beginning at the 
margin, we shall soon succeed in our en- 
deavors. In some cases, however, small frag- 
ments are so firmly adherent as to require the 
dull curette for their removal. If every part 
of the placenta is adherent, it cannot well be 
detached without tearing it into sections. 

If irregular uterine contractions are found, they should be 
overcome by manual dilatation to a degree sufficient to admit 
of separation and removal of the secundines. 

After the adhesions are overcome, the placenta and hand 
should not be withdrawn until the uterus is disposed to con- 
tract, and even then the latter must be followed down with the 
abdominal hand, and held for several minutes. 

The entire operation should be performed without hurry, as 
otherwise the uterine structures may suffer from needless 
traumatism. 

If done under rigid antiseptic precautions, the operation, 




Fig. 256.— Irreg- 
ular Uterine(hour- 
glass)Contraction, 
with retention of 
the Placenta. 



Parturient Anomalies. 



581 



save in those cases which require a good deal of effort to peel 
off an adherent placenta, is comparatively harmless. 

Acute Inversion of the Uterus.— This is a comparatively 
infrequent accident of labor. In the Kotunda Hospital, Lon- 
don, out of 190,800 cases it was seen but once. The only in- 
stance of the kind which has fallen under our notice was in 
consultation practice, and was reported to the Clinical Society 
of Hahnemann Hospital some years ago. 

It consists in turning the uterus inside outwards, as we 
would invert the finger of a glove. 

There are two varieties, the complete and the incomplete. 





Fig. 257. — Incipient Inversion. 



Fig. 258. — Showing commencement 
of Inversion at the Cervix. 



In the former the organ presents by its inner surface at the 
vulva, and may even protrude between the thighs. 

There is no doubt that the accident has in many instances 
occurred as the result of too forcible traction on the umbilical 
cord, In our own case this was the evident cause, the woman 
having been delivered by an ignorant midwife. The traction 
which produces inversion is not always voluntary. The cord 
may be so short that delivery cannot be completed without 
considerable strain on it, while again, birth taking place when 
the woman is on her feet, as occasionally happens, the falling 
foetus gives it a strong pull. 

It may arise also from inattention to the condition of the 



582 Labor. 

uterus while pressure is being exerted on the fundus uteri for 
the purpose of delivering the after-birth. If the organ is re- 
laxed, its fundus may be indented like a hollow rubber ball. 

Dr. Tyler Smith believes that the accident may be occasioned 
by irregular uterine contraction, independently of every other 
circumstance. 

Inversion may begin at the cervix, instead of the fundus 
uteri, as pointed out by Duncan, and in some cases become 
complete. 

Symptoms. — Dr. Meadows, who has met two cases of the 
kind, gives the symptoms so clearly, and yet concisely, that we 
quote him here . ' ' The symptoms of inversio uteri are generally 
pretty well marked, and are, always, of a serious and alarming 
character in proportion to the amount or degree of inversion ; 
they have reference chiefly to the nervous system, which gives 
evidence of very severe shock. In the slighter cases there is 
great pain, of a dragging or bearing-down character, situate 
chiefly in the back and groins, with more or less hemorrhage— 
1 the patient suffers under an oppressive sense of sinking, with 
nausea or vomiting, cold clammy sweats, feeble, fluttering, or 
nearly extinct pulse, faintings, or even convulsions.' These are 
the kind of symptoms which always occur to a greater or less 
extent; but ' the most universal symptom is a sudden exhaus- 
tion, which comes on immediately after the inversion.' The 
amount, both of the hemorrhage and of the pain, varies : they 
are greater in the complete than in the incomplete version ; and, 
as a general rule, though the symptoms are less severe in 
appearance in the latter than in the former, they are not so in 
reality, for the shock to the nervous system has been so great 
that, in some instances, the patient has died almost imme- 
diately. 

"On examining the abdomen, we shall probably not be able 
to feel the uterus at all, while per vaginam a round hard tumor 
will be felt, which may be visible even beyond the external 
parts. It is of a bright red color, its surface being smooth and 
bleeding; the size of the tumor will vary with the amount of 
inversion, and partly also with the time which has elapsed 
since it took place. In recent cases, there is generally a good 
deal of swelling, possibly from the return of blood being pre- 
vented by the narrow constriction of the now inverted os." 

Diagnosis. — The only condition with which acute inversion 
of the uterus is very liable to be confounded is that of uterine 



Parturient Anomalies. 



583 



polypus. From this it will be distinguished by the absence of 
the contracted uterus from the hypogastrium, and the utter- 
inability to pass the uterine sound. Should the placenta remain 
adherent, as sometimes happens, it would serve to dispel any 
doubt concerning the inversion which might otherwise exist. 

Treatment.— The following we borrow from Play fair: "The 
treatment of inversion consists in restoring the organ to its 




Fig. 259.— Complete inversion of the Uterus. (Boivin and Duges.) d, 
clitoris, h, mucous surface of inverted organ. 6, right labium majus. c, 
right labium minorum. e, meatus urinarius. 



natural condition as soon as possible. Every moment's delay 
only serves to render restoration more difficult, as the inverted 
portion becomes swollen and strangulated; whereas, if the 
attempt at reposition be made immediately, there is generally 
comparatively little difficulty in effecting it. Therefore, it is of 
the utmost importance that no time should be lost, and that we 
should not overlook a partial or complete inversion. Hence the 



584 Labor. 

occurrence of any unusual shock, pain, or hemorrhage after 
delivery, without any readily ascertained cause, should always 
lead to a careful vaginal examination. A want of attention to 
this rule has too often resulted in the existence of partial inver- 
sion being overlooked, until its reduction was found to be 
difficult or impossible. 

"In attempting to reduce a recent inversion, the inverted 
portion of the uterus should be grasped in the hollow of the 
hand and pushed gently and firmly upwards into its natural 
position, great care being taken to apply the pressure in the 
proper axis of the pelvis, and to use counter-pressure, by the 
left hand, on the abdominal walls. Barnes lays great stress on 
the importance of directing the pressure towards one side, so 
as to avoid the promontory of the sacrum. The common plan 
of endeavoring to push back the fundus first has been well 
shown by McClintock to have the disadvantage of increasing 
the bulk of the mass that has to be reduced, and he advises 
that, while the fundus is lessened in size by compression, we 
should, at the same time, endeavor to push up first the part 
that was less inverted, that is to say, the portion nearest the 
os uteri. Should this be found impossible, some assistance 
may be derived from the manoeuver, recommended by Merriman 
and others, of first endeavoring to push up one side or wall of 
the uterus, and then the other, alternating the upward pressure 
from one side to the other as we advance. It often happens as 
the hand is thus applied, that the uterus somewhat suddenly 
reinverts itself, sometimes with an audible noise, much as an 
India-rubber bottle would do under similar circumstances. 
When reposition has taken place, the hand should be kept for 
some time in the uterine cavity to excite tonic contraction ; or 
Barnes' suggestion of injecting a weak solution of perchloride 
of iron may be adopted, so as to constrict the uterine walls, 
and prevent a recurrence of the accident. 

" It is hardly necessary to point out how much these maneu- 
vers will be facilitated by placing the patient fully under the 
influence of an anaesthetic. 

"There has been much difference of opinion as to the man- 
agement of the placenta in cases in which it is still attached 
when inversion occurs. Should we remove it before attempting 
reposition, or should we first endeavor to reinvert the organ, 
and subsequently remove the placenta? The removal of the 
placenta certainly much diminishes the bulk of the inverted por- 



Parturient Anomalies. 585 

tion, and, therefore, renders reposition easier. On the other 
hand, if there be much hemorrhage, as is so frequently the case, 
the removal of the placenta may materially increase the loss of 
blood. For this reason, most authorities recommend that an 
endeavor should be made at reduction before peeling off the 
after-birth. But, if any difficulty be experienced from the in- 
creased bulk, no time should be lost, and it is in every way 
better to remove the placenta and endeavor to rein vert the 
organ as soon as possible. 

"Supposing we meet with a case in which the existence of 
inversion has been overlooked for days, or even for a week or 
two, the same procedure must be adopted ; but the difficulties 
are much greater, and the longer the delay, the greater they are 
likely to be. Even now, however, a well conducted attempt at 
taxis is likely to succeed. Should it fail, we must endeavor to 
overcome the difficulty by continuous pressure applied by means 
of caoutchouc bags, distended with water and left in the vagina. 
It is rarely that this will fail in a comparatively recent case, 
and such only are now under consideration. It is likely that 
by pressure applied in this way for twenty-four or forty-eight 
hours, and then followed by taxis, any case detected before the in- 
volution of the uterus is completed maybe successfully treated." 

In our own case the inversion had existed for some two or 
three days when we first saw the woman. The pulse was rapid 
and the temperature high, besides which the lochia were foetid. 
Reposition was effected by means of Guernsey's uterine ele- 
vator, after a fruitless attempt with the fingers. The patient 
made a good, but slow, recovery. 

Several cases are on record in which efforts at reposition 
were unsuccessful, but in which, nevertheless, spontaneous 
reposition subsequently took place. 

Suspended Animation, or Asphyxia Neonatorum — 
Asphyxia of the foetus may be brought about in several ways. 
While the child remains wholly in utero, its supplies of oxygen 
are received through the utero-placental circulation ; but when 
expulsion has taken place, and in some cases even before it is 
completed, they are obtained in the usual manner through the 
pulmonary structures. Hence anything occurring during intra- 
uterine life to interrupt the utero-placental circulation, and 
anything intervening during complete or incomplete extra- 
uterine existence to obstruct respiration, will give rise to 
asphyxia. It follows that we have among the causes of intra- 



586 Labor. 

uterine asphyxia, premature separation of the placenta, com- 
pression, stenosis and torsion of the umbilical cord; and among 
the causes of extra-uterine asphyxia, the presence of mucus 
and fluid in the throat and lungs, and retraction of the tongue. 
Long continued interruption of the foetal circulation, and the 
presence of mucus in the throat from premature respiratory 
eiforts, are the most common causes. We should add, however, 
that premature interruption, or lowering of the foetal circula- 
tion, not only deprives the foetus of its necessary supplies, but 
the very interruption stimulates respiratory efforts, which re- 
sult only in filling the lungs with mucus, blood, and liquor 
amnii, thereby adding to the gravity of the case. 

"Experience has shown," says Schroeder, "that pressure on 
the brain during labor may be attended by the most serious 
consequences to the child. It remains to be seen in what way 
these unfavorable results of cerebral pressure can be explained. 
It may well be doubted whether pressure upon the medulla 
oblongata so irritates it as to produce the first inspiratory 
movement ; at any rate, prolonged cerebral pressure, through 
irritation of the vagus, slackens the pulse and diminishes the 
irritability of the medulla oblongata because the exchange 
between the maternal and the foetal blood is impeded, and, con- 
sequently, the blood circulating in the foetus is poorer in oxygen. 
By cerebral pressure, therefore, the child becomes comatose, 
and this may assume such a degree that the usual irritations 
are no longer able to produce inspiratory movements. The 
child is exposed to such a danger by compression of the head 
within a contracted pelvis, or by the firmly compressed forceps. " 
Effusion of blood into the hemispheres is well borne by new-born 
infants ; but effusion at the base of the brain is fatal. 

Morbid Anatomy. — Schultze describes two stages — asphyxia 
livida and asphyxia pallida. Some writers speak of them as 
distinct forms of asphyxia, but we regard them as different 
stages of the same process. In the first stage, tonicity of the 
muscles remains, and reflex movements are easily excited. The 
skin is dusky ^red, the cutaneous vessels are turgid, and the 
eyeballs protrude. The heart beats slowly, but forcibly. Spon- 
taneous respiration is often set up, or can usually be excited 
without much difficulty. In unfavorable cases the child soon 
passes into the second stage. 

In the second stage, or asphyxia pallida, the child is anaemic, 
the body cold and limp, and the sphincters are relaxed. Reflex 



Parturient Anomalies. 587 

movements cannot be excited. Pulsation is rapid and feeble. 
Inspiratory efforts if made at all, are feeble, and are not par- 
ticipated in by the facial, nasal, or maxillary muscles. 

Diagnosis mid Prognosis.— Schultze claimed to have prac- 
ticed auscultation of intra-uterine respiration with success, while 
many have heard the intra-uterine cry (vagitus uterinus). 
Diminished frequency and force of the foetal heart-sounds, per- 
sisting during the intervals between pains, indicates the begin- 
ning of asphyxia. When delivery has been partially effected, 
the failing pulse and the cyanosis give evidence of the condi- 
tion. Dr. Garrigues reports a case of asphyxia wherein he 
practiced artificial respiration for a period of two and a half 
hours before the child made the first respiratory gasp. It died 
seven hours later. Poppel found that the mortality of asphyx- 
iated children in the first eight days after delivery is seven 
times greater than that of the unasphyxiated, and the mor- 
tality in the first week is in direct ratio to the duration and 
gravity of the symptoms attending the asphyxia. 

Treatment.— There are three indications for treatment, 
namely: 1. The child must be brought as rapidly as possible 
into a position to inspire atmospheric air. 2. Impediments to 
respiration must be removed from the air passages. 3. If the 
irritability of the medulla oblongata has been so weakened 
that no spontaneous inspirations, or only very feeble ones, are 
made, the normal condition of the central organ must be 
restored by artificial respiration. 

With respect to the first indication, no special directions are 
necessary, as the various modes of accelerating labor have 
received attention in other chapters. 

Mucus may be cleared from the throat by inverting the 
body, and passing the finger over the base of the tongue. 

In those simple cases where the child does not at once 
breathe, yet the heart and cord pulsate normally, a slap on the 
nates, simple elevation and lowering of the arms a few times, 
or the sudden application of heat or cold, will suffice to arouse 
the respiratory forces. 

The third indication alluded to may be accomplished by 
several methods. 

Sylvester's Method. — This consists in drawing forward the 
tongue, placing the infant on its back, and extending the arms 
above its head. This movement, which favors inspiration, is 
then followed by bringing the arms down to the sides and com- 



588 



Labor. 



pressing the thorax. These movements should be repeated 
about twenty-five times per minute. 

Marshall HalTs Method. — Place the child in a prone posi- 
tion, which favors, expiration by compressing the chest. Then 
roll it onto its right side, which expands the thorax. These 
movements should be repeated a like number of times per min- 
ute as the foregoing. 

Schrwdefs Method. — In this 
method inspiration and expiration 
are produced by alternately extend- 
ing and flexing the spine in the fol- 
lowing way: "The thorax can be 
dilated by supporting the back ; the 
head, pelvis and arms being allowed 
to fall backwards. A powerful ex- 
piration is then obtained by bend- 
ing the child over the abdominal 
surface, thereby compressing the 
thorax." 

Schultze's Method.— It consists 
of the following manipulations: If 
the heart is beating strongly, and 
the child is only in the livid stage 
of asphyxia, the cord is not cut, but 
the mouth is cleared out, and cold 
water spurted on the pit of the 
stomach and nape of the neck. If 
the heart's action is w r eak to begin 
with, or becomes weak, the cord is 
severed, two or three teaspoonfuls 
of blood are allowed to escape, and 
the child is dipped suddenly up to 
the neck in cold water. If this fail, or 
if the child be born in the pallid stage, after dividing the cord, 
clearing the throat and pulling forward the tongue, the ac- 
coucheur puts the child through the following movements : It 
is so held between the legs of the accoucheur, if sitting, or in 
front of him if standing, that the thumbs are placed upon the 
anterior surface of the thorax, the index finger in the axilla, 
and the other fingers along the back ; the face of the child is 
turned away from the accoucheur. The child, thus grasped, is 
then swung upwards, so that the lower end of the trunk turns 




Fig. 260.— Schultze's method. 
(Inspiration.) 



Parturient Anomalies. 



589 



over towards the accoucheur, and by bending the trunk in the 
region of the lumbar vertebra?, the thorax is greatly com- 
pressed. By such passive expiratory movements the inspired 
liquids pass abundantly out of the respiratory opening. A 
very powerful inspiration is then 
produced by extending the body of 
the child by swinging it backwards 
so as to return it to its previous 
position. In this way expiration 
and inspiration are repeated until 
they become spontaneous. 

The success of this method de- 
pends on careful attention to the 
following points: (1) The first 
movement must be that of expira- 
tion, as otherwise the fluids will be 
drawn still deeper into the air pas- 
sages. (2) The downward move- 
ment must be a sharp swing, or the 
effect on the diaphragm will be 
almost wholly lost. (3) If when 
making the downward movement 
there is no sound of air entering 
the lungs, we are to infer either 
that the swing has not been power- 
ful enough, the hands have pre- 
vented free movement of the chest 
walls, or the glottis is closed. If 
the latter prove to be true, the 
catheter should be introduced and 
held in place while the swinging is 
resumed. 

Howards Method.— The child is 
laid on its back on the operator's 
left hand, the ball of the thumb 
supporting the back and extending the spine, thereby causing 
the shoulders to droop and the head to bend downwards and 
backwards. The buttocks and thighs are supported by the 
operator's fingers. The thorax is then grasped by the right 
hand, and by means of it, while the left affords counter- 
pressure, the chest is compressed, and allowed to expand, at 
the rate of from seven to ten times per minute. 




Fig. 261. — Schultze's method. 
(Expiration.) 



590 Labor. 

Pacini's Method. — In this the feet are fixed, and the operator 
standing with the head against his own body, seizes the arms 
at the axilla? and pulls the shoulders upwards and forwards, 
then allowing them to return to their natural position. This 
movement is to be repeated fifteen or eighteen times per 
minute. 

Comparative Value of These Methods.— Some years ago, 
Dr. F. H. Champneys, of St. George's Hospital, London, 
instituted a series of experiments on the bodies of new-born 
children to determine as far as possible the relative quantity of 
air drawn into the lungs in the practice of these and other 
methods. Following are his conclusions : Since the position of 
equilibrium of a still-born child's chest is one of absolute expi- 
ration, airlessness, or collapse, no method which depends on 
elastic recoil of the chest walls will introduce air into the lungs. 
The methods of Marshall Hall and Howard are useless as 
means of directly ventilating the lungs of still-born children. 
Sylvester's method, and its modifications by Pacini and Bain, 
introduce more air into the lungs than any other method. 
Schrceder's method is useless. Schultze's plan, although its 
power of ventilation is less than that of Sylvester and its modi- 
fications, yet acts efficiently. 

We prefer Sylvester's method for ordinary cases, and 
Schultze's for the graver ones. 

After respiration has been established, the child must be 
watched until it has gained its natural red color, moves the 
limbs actively, and cries with a loud voice. 



Obstetric Operations. 591 



CHAPTER XVIII. 

OBSTETRIC OPERATIONS. 



The Induction of Premature Labor.— This operation, 
introduced by English obstetricians more than a century ago 
to conserve the interest of both mother and child, may be 
employed with benefit in three varieties of cases : ( 1 ) In moderate 
degrees of pelvic deformity. (2) In diseases which imperil ma- 
ternal life. (3) In habitual death of the foetus. 

Prognosis.— Artificial interruption of the orderly progress 
of gestation is always attended with increased risk to the 
woman. According to the most reliable statistics, about 5 
per cent, of the mothers and 50 per cent, of the children are 
lost. Statistics based exclusively on the more advanced 
methods of management of both mother and child would doubt- 
less show a much smaller mortality. In the same connection 
we are to recollect that the operation is performed in a large 
percentage of cases to facilitate the delivery of foetuses through 
contracted pelves, in which parturient dangers are great with- 
out reference to induced action. 

Methods of Operating.— There are a number of methods 
by means of which uterine contractions can be provoked, but 
they differ considerably in their applicability to particular cases, 
their general efficiency and their safety. Those which we shall 
mention are among the most approved. 

Rupture of the Membranes. — This is effective but not always 
prompt. It is the oldest, and also the safest when applied in 
suitable cases. If the premature labor is being induced because 
of pelvic deformity, we should beware of destroying all hope 
of easy version by removal of the amniotic fluid. 

At this period in pregnancy the operation is best performed 
in most instances by means of a sound or catheter, but the 
finger is always to be preferred when it can be employed. 

Artificial Dilatation of the Os Uteri.— -In these cases it is 
chiefly the internal os which offers resistance. Tents are dan- 
gerous instruments, and their use should be discountenanced. 
We regard the finger, and well constructed rubber dilators, 
as far preferable. The finger is less likely to do harm than any in- 
strument which can be used, but it cannot always be made to 
penetrate the internal os without the employment of unwarrant- 



592 Labor. 

able force. If this is true, a steel dilator should be carefully 
used wheu Barnes' bags can be made to carry the dilatation 
to a point where nature will readily complete it. 

Introduction of a Catheter or Bougie.— For this purpose a 
soft rubber catheter is to be preferred, but a gum-elastic one 
will answer the purpose. When the former is chosen, a stylet 
will be required to give it sufficient stiffness to make sure of pene- 
tration. In multipara? the operation is not at all difficult; 
but in primiparae it is not so easy. For convenience* sake the 
woman should be drawn to the edge of the bed and placed in 
the lithotomy position. Using the fingers as a director, the 
point of the instrument is carried within the os uteri, and then 
turned to one side so as to avoid rupturing the membranes. 
After deep penetration, the stylet should be withdrawn and the 
catheter left. The soft catheter can be curled up so that its 
proximal extremity will be within the vagina; but the pro- 
truding end of the gum-elastic instrument should be cut off. 

This operation is quite safe when done under antiseptic 
precautions; and is usually effective. Uterine action is set up 
within a few hours. It is often adopted as a supplement to 
another operation, such as Kiwisch's douche, or Faradization. 

Intra-Uterine Injections. — For this purpose a gum-elastic 
catheter is introduced between the membranes and uterine 
walls, for a distance of about two or three inches, or farther, 
and through this a few ounces of water, at about the tempera- 
ture of the body, is injected. If the first injection fails to 
excite uterine action, it should be followed by another. The 
use of this method has several times been attended with sudden 
death, attributed to entrance of air into the uterine veins, to 
shock, and to rupture of the uterus, and hence has not received 
professional approval. 

Cervical Douche. — Kiwisch's douche consists in directing a 
continuous stream of warm water against theos uteri by means 
of a tube connected with a fountain syringe, or an apparatus 
which operates on the same principle. Some prefer the alternate 
use of hot and cold water. The injection should be repeated 
once or twice a day, for ten or fifteen minutes at a time, until 
uterine contractions are excited. Twelve are said to be about 
the average number required. In urgent cases they may be em- 
ployed every three or four hours ; but the method is not well 
adapted to cases in which rapid delivery is desirable. 

This method has by some been changed, measures being 



Obstetric Operations. 593 

taken to prevent escape of the injected fluid from the vagina, 
with a view to effecting anatomical detachment of the mem- 
branes from the uterine walls ; but the innovation has proved 
a dangerous one. The operation as originally recommended is 
comparatively free from risk, but is often provokingly slow in 
its action. At one time the method was extremely popular, but 
it has now fallen into comparative disuse, except as a means of 
effecting preliminary dilatation of the os. Still we regard it 
as a very appropriate one for certain exceptional cases. 

A much more rapid and far more effective method is that 
described by Thomas. "The method of inducing premature 
labor which I now invariably adopt," he says, "is very simple, 
and, at the same time, a perfectly efficient one. The patient is 
placed across the bed, with the buttocks near the edge, and 
under her is arranged a large piece of rubber or oil-cloth in 
such a way as to drain into a tub on the floor. In this tub we 
put one or two gallons of water of a temperature of 98° F. 
The operator stands between the thighs of the patient, whose 
knees should be properly supported, and employing a syringe 
with a long nozzle, which is carried up as far into the cervical 
canal as it will go, he keeps a steady stream directed against the 
membranes. In the course often minutes the os will be the size 
of a silver half dollar, and when dilatation to this extent has 
been accomplished, he is to insert a gum catheter between the 
membranes and the uterine w r alls. The patient is then put in 
bed, and that is all." 

Dr. Schrader, of Hamburg, has published a method of induc- 
ing premature labor, based on his observation that cold is a 
greater excitant of the nervous, and consequently also of the 
muscular, system, than warmth. Continuous irrigation at the 
temperature of 45° F. is impracticable on account of the pain 
it causes, but a cold douche, alternating with a warm one, can 
be borne. Dr. Schrader connects a vaginal glass tube, by means 
of a T-shaped piece and the necessary india-rubber tubes, to two 
irrigators, one of which contains the cold, and the other the 
warm water. By allowing now one instrument and now the 
other to work, cold or warm water may be sent through the 
vaginal tube into the vagina. Two people are required— the 
one to fill the irrigators, the other to work the douche. For 
each sitting about twenty-four liters of cold, and half the 
quantity of warm water, at 112° F., are required, and the 
douche has a fall of about one meter and a half. The irrigation 
(38) 



594 Labor. 

begins with the warm current, and, before the cold water is 
turned on, pressure is made on the perineum with the vaginal 
tube, so as to allow all the warm water to run away from the 
vagina. The same plan is observed before the change from cold 
to warm, by which means the alteration in the temperature as 
felt by the patient is always sudden. Each time about two 
liters of cold and half the quantity of warm water are used. 
The douche is generally repeated about every hour and a half 
until labor is active enough to make its continuance probable. 
Of eighteen women treated by this method exclusively, and 
four others who were partly so treated, one died of eclampsia 
twelve hours after delivery, but all the others made a good 
recovery. The eighteen women who were treated by the douche 
exclusively, had twenty children, of whom fifteen, that is, 
seventy-five per cent., were alive. These cases required on the 
average ten douches and a half; in half the number three 
douches and a half were sufficient. 

Introduction of Foreign Bodies into the Vagina. — Braun's 
colpeurynter, Gariel's air pessary, and the ordinary tampon, 
have been used as means of inducing premature labor. The 
effect is excitation of reflex uterine action, and more or less 
mechanical dilatation of the os uteri, with separation of the 
membranes. These measures, tolerably safe and certain w T hen 
carefully employed, are not highly regarded by the most skillful. 
Distension of the vagina should not be excessive, and must 
not be long-continued or the vaginal tissues will be liable to 
suffer. 

Use of Electricity. — Electricity is an efficient means of bring- 
ing about premature interruption of pregnancy. The Faradic 
current, by exciting contraction of the muscular fibers, proves 
of greater service in this direction; though the galvanic current 
has been successfully employed. With the anode on the lumbar 
region, and the cathode on the abdomen, a mild current should 
be administered for fifteen or twenty minutes, and repeated at 
short intervals until uterine action is well established. 

The Induction of Abortion.— The physician is certainly 
justifiable in inducing abortion whenever the operation offers 
the best chance of saving the woman's life, but only after due 
consideration, and when his conviction of its advisability has 
been strengthened by counsel. The main conditions which unite 
to demand the operation are: (1) Incarceration of the pro- 
lapsed or retroflexed uterus, when the dislocation cannot be 



Obstetric Operations. 595 

reduced, and (2) Diseases of pregnancy which greatly endanger 
life, and which have refused submission to all carefully chosen 
remedies. 

We believe it is equally justifiable to induce abortion in those 
cases of extreme pelvic deformity, or of pelvic tumors, which 
are quite sure to make the performance of abdominal section a 
necessity, should pregnancy be permitted to go on. 

The operation is performed by introducing a sound, and 
sweeping it about in the uterine cavity ; by introducing a soft 
catheter ; or better still, by the intra-cervical use of electricity. 



596 Labor. 



CHAPTER XIX. 

OBSTETRIC OPERATIONS— Continued. 

Turning. — Turning consists in the performance of a maneu- 
ver by means of which one presenting part is exchanged for 
another, as when the head, in a case of placenta previa, is 
converted into a footling presentation, or the shoulder, in a 
transverse case, is changed into a cephalic presentation. 

Two general varieties of turning are practiced, namely, the 
cephalic and the podalic. Among the ancients, cephalic version 
only was practiced, under the mistaken idea that labor could 
not well be terminated with the pelvic extremity in advance. 
The form of version now most popular, and which in general is 
more easily and safely performed, is the podalic, which consists 
in bringing down the feet when some other part presents, and 
thereby converting the case into a footling presentation. 

Conditions Calling for the Operation. — The circumstances 
which unite to designate this as the suitable operation are 
various. Resort is sometimes had to it as a speedy means of 
delivery in urgent cases, while in other instances it constitutes 
the only means of terminating labor without mutilation of 
either mother or child, and is so recognized from the start, though 
not hurriedly adopted. Among the conditions demanding this 
sort of interference we may mention placenta previa, transverse 
presentations, certain degrees of pelvic contraction, prolapse of 
the funis, sudden death of the mother, and some cases of uterine 
rupture. 

Favorable Conditions. — The most prominent of these is 
retention in utero of the amniotic fluid, to which we may add 
leisurely and unenergetic action of the uterus. Version by ex- 
ternal manipulation should not be undertaken after the amni- 
otic sac has been emptied, but version by the internal method 
can many times be done with comparative ease when the waters 
have not long been absent. For all but external version it is 
essential that there be a certain amount of cervical dilatation, 
or at least cervical relaxation. 

Cephalic Version.— This form of version is not often prac- 
ticed, chiefly for the reasons that it requires the concurrence of 
so many favorable conditions, and that the circumstances which 
necessitate version are usually of so pressing a character as to 



Tukning. 597 

require the speedy termination of labor, a thing not always 
easily accomplished in connection with cephalic version. Still, 
in some favorable cases it is the preferable mode. 

The operation can occasionally be practiced by external 
manipulation alone, but it usually requires the combined in- 
ternal and external method. 

To perform the external manoeuver, the woman should be 
placed on her back with her hips raised above the level of her 
head and shoulders, so as to place the long uterine axis more 
nearly in coincidence with a horizontal plane, and the knees 
elevated. The abdomen must be exposed, or covered only with 
some thin material. By abdominal palpation the two poles of 
the long foetal diameter, namely, the pelvic and cephalic, are to 
be located, and the hands placed upon them. Operating then 
between pains, an attempt is made to push upwards the pelvic 
extremity, and to bring the head into the pelvic brim. During 
uterine action the only effort should be to maintain the advance 
obtained. The manoeuver of external version may sometimes 
be aided by turning the woman upon the side towards which 
the head lies, but the position is unfavorable for manipulation. 

After bringing the head into the brim, it may be retained by 
suitable pressure made with the hand, but better still, if the os 
be dilated, by the application of the forceps; or the membranes 
may be ruptdred and the liquor amnii permitted to escape. 
What answer a- very good purpose as aids to maintenance of 
the acquired presentations are pads applied to the sides of the 
abdomen, along the line of the foetal prominence, held in place 
by a well-adjusted binder. 

By the combined method, that is, by the simultaneous use of 
both external and internal manipulation, cephalic version is 
more easily performed. The method described and practiced 
by Braxton Hicks is probably the preferable one. He prefers 
the lateral decubitus, and uses the left hand when the patient is 
on the left side, and the right hand when she lies on the right 
side. We quote him as follows : " Introduce the left hand into 
the vagina as in podalic version ; place the right hand on the 
outside of the abdomen in order to make out the position of the 
foetus and the direction of the head and feet. Should the 
shoulder, for instance, present, then push it, with one or two 
fingers on the top, in the direction of the feet. At the same time 
pressure by the outer hand should be exerted upon the cephalic 
end of the child. This will bring down the head close to the os ; 



598 



Labor. 



then let the head be received upon the tips of the inside fingers. 
The head will play like a ball between the hands, and can be 
placed in almost any part at will. * * * It is as well, if the 
breech will not rise to the fundus readily after the head is fairly 
in the os, to withdraw the hand from the vagina and with it 
press up the breech from the exterior." 

Anesthesia is neither necessary, nor specially desirable in all 




Fig. 262.— First stage of the Com- 
bined method. 



Fig. 263. — Second stage of the Com- 
bined method. 



cases, for the practice of version by the combined manipula- 
tion, and hence, in such cases, the woman can be made to 
assume a position which is often found to contribute to the 
successful practice of the operation, namely, that upon the 
knees and elbows. 

Podalic Version.— " The reasons why podalic version so 
rapidly displaced in public favor the ancient turning of the 
head," saysGlison, " seem to be chiefly on account of its facility 



Turning. 



599 



of performance, and rapidity in the termination of labor, for it 
is often very difficult to seize, bring down and properly adjust, 
the round, slippery head, by the old method of introducing the 
hand into the womb. By the modern external and bipolar 
modes, especially the latter, the difficulty and danger are so 
much less, that turning by the head, in transverse presentations 
particularly, will become more popular. But where haste is 
necessary, in the latter presentation, as well as in all others 
adapted to turning, podalic version, and that, too, in the regular 
way of introducing the hand into the womb, must be resorted 
to.'" 

The operation may 
be performed by exter- 
nal manipulation, by 
the combined method, 
or by the introduction 
of the hand and seizure 
of the feet. 

Wigand, to whom we 
are mainly indebted for 
the introduction of the 
external method, con- 
sidered it suitable only 
to transverse cases. It 
is practiced so like 
cephalic version by ex- 
ternal manipulation, 
that it requires no spe- 
cial description. 

Position of the Pa- 
tient. — In practicing 
podalic version in any manner, the position generally recom- 
mended by American obstetricians is the dorsal. The patient 
should be so placed that her nates lie near the edge of the bed, 
with her feet resting on chairs, or held by assistants as in for- 
ceps delivery. The abdomen ought either to be uncovered, or 
have over it only a sheet, a light chemise, or a night dress. 
The physician should stand between his patient's feet with his 
face towards her. 

The Combined External and Internal Method. — The position 
and presentation having been determined, and the bladder and 
rectum emptied, the operation is performed much as is that of 




Fig. 264— Third stage of the Combined 
method. 



600 



Labor. 



cephalic version, the two poles of the foetal oval being pushed in 
opposite directions. The whole hand is never introduced into 
the uterus, but it may be necessary to pass it into the vagina, 
on account of the inability to reach and handle the presenting 
part. In some cases chloroform will be required. The pre- 
requisites for success are : Sufficient dilatation of the cervix to 
permit the introduction of two fingers ; a certain degree of foetal 
mobility ; and a clear comprehension of foetal position and pres- 
entation. After rupture of the membranes and escape of the 
waters, the operation becomes difficult, or even impracticable. 
Internal Podalic Version. — This form of version, first prac- 




Fig. 265.— Internal Podalic Ver- 
sion, Arm presentation, dorso-an- 
terior position. 



Fig. 266.— Internal Podalic Ver- 
sion, Transverse presentation, dorso- 
posterior position. 



ticed by Ambrose Pare, consists in introducing the hand into 
the uterine cavity, seizing the feet and bringing them through 
the os uteri and vulva, while the body is made to rotate on its 
transverse axis. Sufficient dilatation is required to admit the 
hand without force, and, save in those cases w T here the utmost 
haste is demanded, the bi-polar, or combined method, should 
first be tried. Internal podalic version, while still the most 
popular mode of turning, is rapidly giving way to the other 
methods. It is the only practicable form of version w r hen the 
liquor amnii has been long drained off, and a certain amount of 
uterine retraction has taken place. 



Turning. 



601 



After the preliminaries as regards diagnosis, position, and 
evacuation of the bladder and rectum have received attention, 
the woman should be drawn to the edge of the bed, and placed 
under anesthetic influence. The physician should take a position 
in front of his patient, with hand and bare forearm well lubri- 
cated, with the exception of the palm, and proceed gently to 
insinuate his hand, the fingers slowly separating and expanding 
the parts, until it finally lies within the uterine cavity. When 




Figs. 267 and 268. — Internal Podalic Version in Cephalic presentation, 
with the fetus in different positions. 

practicable he should choose that hand, the palmar surface of 
which, as it passes, corresponds to the ventral surface of the 
foetus ; but in transverse presentations this is a matter of com- 
paratively slight importance, as by turning the woman there is 
no possible direction within the pelvis or the womb in which 
either the right or the left hand may not be passed. If the 
physician is not ambidextrous, he should use his most efficient 
hand, without reference to the foetal position. 



602 LABOii. 

In cephalic presentations the question of hands is one of 

more importance, and the weight of experience favors the use of 

that hand, the palmar surface of which corresponds to the 

ventral surface of the child ; hence with the woman on her back, 

in first and fourth positions of the foetus, the left hand should be 

used, and in second and third positions, the right. 

After the hand passes the vulva, which it is enabled to do by 

firmly repressing the perineum, it should pause for a moment 

to examine more carefully the presentation and position. Then 

with the external hand upon the fundus uteri, the internal one 

should be most gently urged through the os and cervix uteri. 

If the membranes are now intact, it makes very little difference 

whether we tear them with the fingers and then push onwards 

through them, or pass the hand between the membranes and 

uterine walls until it comes into proximity to the feet, before 

breaking into the amniotic cavity. 

If uterine action is at all forcible, the hand must be extended 

and remain passive 

until the contraction 

passes away; but if 

uterine efforts are 

feeble, and almost 

continuous, as thev 
Fig. 269. — Use of the Running Noose on the foot. , • -i 

s sometimes are, slow 

but resolute progress should be insisted upon. 

Obstetricians are at variance respecting the question of seiz- 
ing one foot, or both feet, for the performance of version. The 
safe rule of practice is to grasp both feet or knees if they lie 
within convenient reach, especially if there be an urgent demand 
for delivery ; but, if both limbs cannot be easily seized, the most 
accessible one ought to be brought down without unnecessary 
delay. If the demand for delivery be not pressing, and both 
feet be within reach, we believe it advisable to take but 
one, but to make ourselves sure that the one selected is the 
desirable one. There is a positive advantage derivable from 
bringing down but a single foot, or knee, since by leaving one 
still flexed upon the body, greater dilatation of the os uteri, 
the vagina and the vulva is necessitated by the passage of the 
pelvic portion of the foetus, and the difficulties and dangers of 
head extraction are thereby diminished. 

That there is a difference in desirability between the two legs, 
we are fully convinced, and the preferable one is that which lies 




Turning. 



603 



towards the abdominal parietes. The advantage in seizing this 
is found in the greater facility with which the foetus rotates on 
its longitudinal axis, and so descends that the head will engage 
the pelvis with the occiput looking forwards. This advantage is 
clearly demonstrable on the manikin. Yet this is not a ques- 
tion of such practical importance as to demand much consider- 
ation. 

In cases of turning where there is pelvic contraction, when 
extraction is likely to be difficult, it is regarded by some as 




Fig. 270. — Turning by the Noose or Fillet. 

highly advisable to bring down both legs; but the practical 
advantage of doing so, even there, is not obvious, since the 
rejected leg becomes free before the shoulders pass the vulva, 
and the special difficulty is in connection with extraction of the 
head. 

Unless care be exercised, the elbow is liable to be mistaken 
for the knee, and the hand for the foot; but ordinary attention 
will prevent our falling into such an error. 

While drawing down the foot, or feet, with the internal 
hand, an effort should be made to push upwards the head with 
the external. Before relaxing our hold on the feet we should 



604 Labor. 

make sure that the version is complete, as otherwise the foetus 
is liable to be spontaneously restored to its original position. 
If the head refuse to ascend, a running noose of gauze, or other 
suitable material, should be slipped around the foot, and trac- 
tion made on it by one hand, while the fingers of the other are 
used within the os uteri to push the head upwards. 

In some difficult cases of turning it is unwise to relax our 
hold of the foot for the purpose of putting a noose on it, since 
the incompleteness of version may cause it to retract beyond 
ready reach and thereby occasion much trouble. To apply the 
fillet while still retaining a hold of the foot it will be necessary 
to noose the former about the arm and gradually work it up- 
wards until it reaches the foot. 

If version cannot be completed with one foot, the other must 
be brought down. 

When, in transverse presentations, the arm descends into the 
vagina, it somewhat embarrasses version, but does not prevent 
it. In such cases it is a good plan to place a noose of tape about 
the Avrist, which enables the operator to control the arm, both 
while his hand passes into the uterine cavity, and later, during 
extraction of the trunk. 

Completion of the Delivery. —After the desired change has 
been effected, the question arises whether labor should at once 
be completed, or be left to the natural efforts. If there exist no 
urgent demand for delivery, nature may be given a fair oppor- 
tunity ; but the woman is already anesthetized, and very likely 
the pains are in great measure arrested, so that, in general, it 
would seem most wise to proceed carefully to terminate the 
labor. 



The Forceps. 605 



CHAPTER XX. 

OBSTETRIC OPERA TIOXS— Continued. 

The Forceps.— The obstetrical forceps were designed and 
used by one Paul Chamberlen in the early part of the seven- 
teenth century. In 1647, Peter Chamberlen, in a little pamphlet 
published by him, speaks of a discovery made by his father, 
Paul Chamberlen, for saving the lives of children during labor. 
It, however, remained a family secret, bringing its possessor 
immense gain, and did not become public until 1733, in which 
year Dr. Chapman, in a brief treatise on obstetrics, said that 
"the secret mentioned by Dr. Chamberlen was the use of 
forceps, now well known to the principal men of the profession, 
both in town and country." In another edition of his work, 
published two years subsequently, he gave a cut of the instru- 
ment, which was afterwards known as Chapman's forceps. 

Since that day this most useful obstetric instrument has 
undergone such change in form and applicability as to render 
it much more useful. 

As at first designed, the forceps were intended for application 
to the head when lying in the pelvic cavity or at the outlet; 
though they were sometimes used at the brim. One change in 
the forceps was in the direction of augmented length, with the 
design to provide an instrument capable of grasping the head 
at the pelvic brim, or even above, and the result is that we now 
have the long forceps and the short forceps. 

The Short Forceps.— The short forceps owe their brevity 
chiefly to the abbreviation, or entire absence, of the shank, and 
the shortness of the handle : the fenestrated portion of the in- 
strument not being materially less than the same part of the 
long forceps. The instrument is recommended mainly because 
of its easy portability, and the possibility, in some cases, of 
robbing the operation of forceps delivery in great measure of 
the formidable aspect, which, in the patient's eyes, it is so apt 
to assume. It is claimed by those who advocate frequent use of 
this instrument, that it can be applied even without the patient's 
knowledge. We know from experience that it is usually of easy 
application, but that it can be gotten on, while the woman is 
wholly conscious, without attracting her attention, we have not 
often found to be true. 



606 



Labor. 




Fig. 271. — Chamberlen's Forceps. 



Most patterns of short forceps possess the usual cephalic, 
but very little of the pelvic, curve, the latter not being required 
in low applications for which this instrument is intended. 

The Long Forceps. — Since it has been found in practice 
that the long forceps may be applied, not only at the brim, and 
above it, but also in the pelvic cavity and at the outlet, — in 
fact, that they answer almost equally well the purposes of the 
short, — most of the instruments at present manufactured are of 
the long variety. 

Without commenting 
on the different patterns 
of forceps which we find 
in the instrument shops, 
we have become con- 
vinced, from use of many 
of them, that, while Ave 
cling to instruments of a 
certain form, our prefer- 
ences may proceed largely 
from frequent use, for 
there are few of the more 
prominent varieties which 
are really objectionable. 
The features to be sought 
are handles of moderate 
leugth; blades as light as 
are compatible with great 
strength ; a cephalic curve 
sufficiently acute to afford 
a hold on the head which 
will not slip, even when 
taken over its long diameter ; and a pelvic curve acute enough 
to enable the point of the blades easily to clear the sacral 
promontory without requiring excessive depression of the 
shanks against the perineum. 

The Salient Features of the Instrument.— The blade of 
the instrument is constructed with a fenestra varying in width, 
and slightly so in general shape. This part of the instrument 
requires to be strongly made, and none but the best quality of 
steel should be used in its construction. 

In order to give the blade a firm hold of the head, it is pro- 
vided with what is termed the cephalic curve. We believe with 




f SHARP &SMVm. 

Fig. 272. — Stone's short Forceps. 




Fig. 273. — Knox's short Forceps. 



The Forceps. 607 

Dr. Landis that, " with a proper head-curve the tips of the 
"blades will approximate to such an extent, when the instru- 
ment is applied, that traction upon the blades brings their 
distal end upon the farther end of the head, so as to not only 
securely hold it, but also to push it onwards. When forceps are 
said to slip during their use, one of two things is certain ; either 
the head-curve of the instrument is insufficient, or the blades 
have not been properly applied." He should have added, per- 
haps, "or traction is not made in the right direction." 

The pelvic curve is a feature of the utmost importance. By 
means of it the forceps are more easily applied, and extraction 
is more easily effected. 

Forceps are provided with a variety of handles. Hodge's 
and Comstock's, for example, have slim metal handles which 
terminate in blunt hooks; but most other patterns have 




Fig. 274. — Reamy's Forceps. 

wooden handles, provided at their distal extremities with 
shoulders or rings, upon or within which the fingers may rest 
in making traction. The wooden handles are far preferable. 
Axis-Traction Forceps.— Ever since the introduction into 
obstetrical practice of the long forceps, there has been a sensible 
need, in some cases, of an instrument of a form which would 
enable the operator to make traction in the line of the axis of 
the plane of the superior strait. The difficulty lies in the curve 
of the parturient canal, which, from brim to outlet, is consider- 
able, as will readily be seen when we recollect that, in the erect 
position, the plane of the brim is at an angle of 60° with the 
horizon, and the plane of the outlet at an angle of 11°. But 
when we recollect also that the head of the foetus does not come 
into the world on the plane of the outlet of the bony pelvis, 
which faces somewhat backwards, but on a plane, the posterior 
boundary of which is the posterior commissure of the vulva, 
and which looks almost directly forwards, we obtain a better 
idea of the extent of the curve of the parturient canal. 



608 



Labor. 




The long forceps, as ordinarily constructed, are provided 
with a curve to conform to the curve of the pelvic axis, and, 
therefore, when the instrument is applied to the head lying at 
the superior strait, or above, and traction made, a certain part 
of the force is dissipated, OAving to our inability to make trac- 
tion in the direct line of the pelvic axis. This effect is easily 
demonstrated on the manikin, or on the dry pelvis, and is well 
illustrated in Fig. 278. 

To be sure, the difficulty presented in the majority of cases 
in which the forceps are used at the pelvic brim, or above it, is 
sufficiently well overcome by the long forceps as ordinarily con- 
structed; but occasionally the brim is either so considerably 

diminished in its 
diameters, or the 
foetal head so hard 
and so greatly aug- 
mented in volume, 
that only by dint 
of powerful traction, 
and the most expert 
management, can 
the labor be brought 
to a successful ter- 
mination. It is in 
such cases, and per- 
haps also in some of 
those which the or- 
dinary forceps can- 
not deliver, that the 
axis-traction instrument is peculiarly serviceable. With it the 
head can be drawn into the brim in a direct course, while with 
the other instruments it is drawn towards the symphysis pubis 
as well as in the direction of the pelvic outlet. 

With a view to overcome the difficulties of delivery attend- 
ing cases like those to which we have referred, Tarnier's forceps 
have been provided, and can be made to serve a useful purpose. 
But the instrument is expensive, heavy, clumsy and extremely 
difficult of application save by experts. 

Various other instruments have been devised to accomplish 
the same end, but in the forceps bearing the author's name are 
found all the essential elements combined in the form of an 
ordinary instrument. These forceps can be effectually, and with 



Fig. 275— Comstock's Forceps. 




Fia. 276.— Leavitt's Forceps. 



The Forceps. 609 

equal facility, applied to the head in all situations, i. e., above 
the brim, at the brim, in the pelvic cavity and at the outlet. In 




Fig. 277. — Tarnier's Axis-traction Forceps. 

other words, they answer the purpose of any other instrument, 
while they also serve an exceptionally good purpose in difficult 




Fig. 278. — Leavitt's Forceps applied to the Head above the brim, showing 
how traction can be made in the axis of the plane of the pelvic brim. 

cases at the brim, and above, by enabling us to make traction in 
the line of the pelvic inlet. We need only add that, in such cases, 
the weight of traction effort should be made near the extremity 
of the handle. 

(39) 



610 



Labor. 



Designations of the Blades.— In English text-books the 
blades" are spoken of as the male and female, and the upper and 
lower. The latter designation has a double meaning, growing 
out of the position of the woman. In English practice the ob- 
stetric position is on the left side, and the lower blade, when 
locked with its mate, is not only beneath or behind the other, 
but is also in the lower side of the pelvis when applied. In 
America, the common, and most convenient designations, are the 
right and left. The right blade is naturally handled with the 
right hand, and usually goes more or less into the right side of 




Fig. 279.— The Forceps at the Brim, by the Pelvic mode. 

the pelvis; w T hile the left blade is more conveniently handled 
with the left hand, and commonly goes more or less into the 
left side of the pelvis. 

Action of the Forceps.— The forceps are primarily and 
essentially tractors. Their action is also, in a modified sense, 
that of levers and compressors, A certain amount of lateral 
oscillation gives greater power to the instrument, and if made 
without relaxation of traction efforts, and within moderate 
limits, it can do no harm. The antero-posterior, or "pump 
handle," movement is always to be avoided. 

The compression force exercised by the forceps should be 
in direct ratio to the force of traction; the chief aim being 



The Forceps. 611 

to retain firm hold. The degree of squeezing which the foetal 
cranium will bear, when compression is made intermittingly and 
not too rapidly increased, is truly surprising. 

Modes of Application. — There are two modes of forceps 
application, namely, the cephalic or oblique, and the pelvic or 
direct. The former is used chiefly in the pelvic cavity, and at 
the outlet ; while the latter is employed more especially at the 
pelvic brim and above it. The cephalic mode is always pref- 
erable, so far as foetal interests are concerned; but, out of 
deference to maternal interests, it is not alwa3 T s advisable. 

The Pelvic Application.— hi adopting this we do not study 
the cranial position, and materially vary our application to suit 
it, but we pass the blades into the sides of the pelvis. Since 
this mode of application is used mainly in the high operations, 
and inasmuch as the foetal head usually occupies an oblique 
pelvic diameter, the blades generally embrace the head over the 
brow, on one side, and the mastoid process on the other. This 
form of application is adopted because of the difficulty and 
danger associated with adjustment of the blades to the sides of 
the head when at such a distance from the vulva, and at the 
farther end of the curved parturient canal. 

The Cephalic Application. — In this we study the position of 
the foetal head, and vary our application to suit it, the endeavor 
always being to apply the blades to the sides of the head. 

Conditions Calling for the Forceps. — "It would be an un- 
profitable undertaking," remarks Lusk, "to enumerate all the 
conditions which render forceps advisable. The indications for 
their use may be summed up in two general propositions. The 
forceps is applicable — (1) In cases where the ordinary forces 
operative during labor are insufficient to overcome the obstacles 
to delivery; (2) In cases Avhere speedy delivery is demanded in 
the interest of either mother or child. 

" Both these propositions are, however, subject to the limita- 
tion that, in the selection of the mode of delivery, choice should 
be made specially with reference to the maternal safety. For- 
tunately, in the great proportion of cases the interests of both 
mother and child are identical." 

The Preliminaries.— When the operation has been decided 
upon, it is advisable in most cases to administer an anesthetic 
before in any way changing the patient's position. An anes- 
thetic is not absolutely required, and some women object to it, 
preferring to suffer the necessary pain rather than take what 



■i^^^MH 



612 Labor. 

they regard as unnecessary risk. If the head lies in the cavity, 
or at the outlet, the pain attendant on forceps delivery is not 
sufficient to make the anesthetic a necessity, and it may be 
omitted. We would advise against partial anesthesia. Either 
let it be entirely omitted, or carried to the extent of complete 
narcosis. Administration of the anesthetic may be begun by 
the operator, and subsequently entrusted to an intelligent 
nurse, or other attendant, provided no skilled assistant is at 
hand. 

It is assumed that the bowels and bladder have been recently 
evacuated. 

The forceps should be thoroughly clean, aud, for a short time 
before their use, should stand in a warm antiseptic solution. 
Meanwhile the membranes, if intact, should be ruptured, and the 
woman turned so that she will occupy the dorsal position, 
across the bed, with the hips well to the edge of it. 

The Application. — We have found but little practical differ- 
ence in application of the forceps, between a high and a low 
head, except in the adoption of the pelvic mode in one case, and 
the cephalic in the other. A proper adjustment of the forceps 
in one case is almost as difficult as in the other. When the 
head lies low, it is within easy reach, but the difficulty is in- 
creased by adoption of the cephalic mode of application. When 
the head lies high, it is not so easily reached, but by the pelvic 
mode the forceps are made to go readily into place. The only 
exceptions to easy application which we have found, have been 
in instances of marked pelvic deformity, large cranium, small 
os uteri and impacted head. 

The patient's feet resting on the edge of the bed, or 
placed in chairs and there held by assistants, the operator as- 
sumes his place directly in front of the woman, and, having 
lubricated the blades, takes the left one in his left "hand, and 
introduces it until the point rests against the foetal head, while 
he uses two or more fingers of the opposite hand, resting against 
the presenting surface, as a guide. The handle at this stage will 
form nearly a right angle with the maternal body, looking 
slightly to the woman's right. Now, remembering the double 
curve of the instrument, it is given a spiral sweep, the handle 
passing over the patient's right thigh, and then made to ap- 
proach the median line, until, in a high application, the shank 
presses firmly on the perineum. A common mistake is that of 
attempting to carry the blade directly to its place without first 



The Forceps. 



613 



passing its point towards the sacral hollow, and then to its 
proper position by a broad spiral sweep. In applying the for- 
ceps to the sides of the head before cephalic rotation has taken 
place, the sweep of one blade will be but slight, while that of the 
other will be unusually great. 

The application of the second blade is made in a similar 
manner, the instrument being held in the right hand, and guided 
by the left. In giving it the necessary sweep, the handle is made 
to pass over the woman's left thigh. 




Fig. 280.— Introduction of the first Blade. 

Both blades now being in situ, we ought to experience no 
difficulty in making them lock. If the adjustment be inac- 
curate the instrument should be gently manipulated, an en- 
deavor being made to bring the blades directly opposite with- 
out the exercise of force. If necessary, one or both blades may 
be removed and reapplication made in order to effect our 
purpose. 

Traction.— The forceps once on, and locked, it next becomes 
the operator's duty to effect delivery, and to do so safely re- 



614 



Labor. 



quires some knowledge concerning traction. The handles of the 
instrument should be held in a convenient way, and so as not to 
exert too great compression of the f fetal head. If the pains con- 
tinue, traction efforts should be made coincidently with them ; 
if they are absent, traction should substitute them. But we 
usually find, as soon as we begin to draw on the forceps, that 
the uterus is excited to action, and the vis a fronte is aided by 
a vis a tergo. Traction energy should at first be moderate, but 
afterwards increased if necessary to a high degree ; but so long 
as the resistance is offered mainly by soft structures, as, for ex- 
ample, an incompletely dilated cervix, or vulva, the utmost 
caution must be exercised. Traction when the head is pass- 
ing the vulva ought 
to be light, through 
fear of lacerating the 
perineum. 

The line of traction 
will be well enough 
indicated by the direc- 
tion naturally taken 
by the handle in the 
intervals between 
pains. In high opera- 
tions it is at first 
dowmwards, and pos- 
sibly a little back- 
wards; but as the 
head descends, it 
should be turned more 
and more forwards, until the handle at the final passage comes 
to form a right angle with the long axis of the woman's body. 
Removal of the Forceps.— When the head is embraced over 
the poles of its bi-parietal diameter there is no necessity for re- 
moval of the forceps until after complete delivery of the head ; 
but when, from adoption of the pelvic mode of application, 
the head is held over its occipito-frontal, or over an oblique 
diameter, in performing rotation the blades will be carried into 
such positions as to endanger the perineum posteriorly, and the 
vestibule anteriorly ; hence we regard careful removal of the in- 
strument a wise precaution. Before doing so the head should 
be made to reach the crowning stage, and then, after removal, 
it can easily be delivered by Fasbender's manoeuver, described 




Fig. 281. — Imperfect seizure of the Head 
above the Brim, favoring slipping of the instru- 
ment. 



The Forceps. 615 

in another chapter, which consists in cranial delivery by means 
of the fingers in the rectum. 

Forceps in Occipito-posterior Positions.— We are told by 
Lusk that "so long as the occiput looks to the rear, it is the 
rule of midwifery practice to refrain from the use of forceps, 
which, of necessity, prevents forwar rotation taking place." 
Moreover, it is added: "As attempts to rotate the occiput 
around to the symphysis by instrumental means are rarely suc- 
cessful, it is advisable under such circumstances to apply the 
forceps directly to the sides of the child's head, and to imitate 
during delivery the mechanism of labor iu occipito-posterior 
positions. If the sagittal suture occupy an oblique diameter, the 
forceps should be applied in the opposite oblique diameter. As 




Fig. 282.— Showing how the Head is usually seized in the Cephalic 
mode of application. 

the head descends, the occiput should be turned into the hollow 
of the sacrum." 

We are convinced from experience that it is possible to do 
much better than this. Accordingly, when there exists a demand 
for the forceps above the brim, with the occiput looking more 
or less backwards, we regard it as the operator's duty to en- 
deavor carefully to rotate the head, so that its long diameter 
will coincide with the transverse of the pelvis, before applying 
the instrument. By virtue of such a change he is enabled, with 
the forceps in the sides of the pelvis, to grasp the head in its 
long axis, and effectually prevent a backward movement of the 
occiput during delivery, and, if requisite, to enforce proper ro- 
tation. On the contrary, when the instrument is so applied 
without the observance of the precaution meutioned, the head 
is seized in one of its oblique diameters, as has already been 



616 Labor. 

shown, and even slight compression during descent disposes the 
occiput to rotate into the hollow of the sacrum. 

This change of position above the brim is so easily accom- 
plished in suitable cases that explicit directions are not required. 
The sinciput, as felt in the hypogastrium, should be pressed 
backwards, whilst the occiput is drawn forwards with the 
fingers of the other hand in the vagina. Having effected an al- 
teration, the acquired position should be maintained by firm 
and equable pressure in the supra-pubic space, until the forceps 
have been adjusted to the head. In default of so doing, the 
head is very liable to revert to its original position. 

Observation has taught us that the head, when clearly above 
the brim, is not always freely movable, and then all prudent 
efforts to change its position will be utterly unavailing. To 
such cases, including as well those in which the head lies within 
the embrace of the superior strait, a different treatment is ap- 
plicable. If the occiput is turned more or less forwards, or 
directly to one side, the physician has but to pass the blades 
according to the usual directions for the pelvic application ; but 
if it is more or less backwards, then, instead of putting the 
blades squarely in the sides of the pelvis, let him, if possible, 
place them on the forehead and occiput (a thing, we confess, not 
always easily done), and thereby embrace the head over the 
poles of its long vertex diameter. 

When once the instrument is fairly adjusted, if the head is 
found to be unfixed in the brim, it may be gently raised and 
carefully rotated from one oblique diameter into the other, but 
the operator should beware of violence. If such a movement 
prove impracticable, the head should be drawn, with usual pre- 
cautions, to the pelvic floor, and then, if the natural efforts are 
ineffectual, the desirable evolution can easily be enforced. 

The forceps are occasionally required in the situations de- 
scribed, but much oftener after the head has descended into the 
pelvic cavity. With respect to the mode of treatment best suited 
to the latter class of cases, a few years appear to have wrought 
a change in the opinion and practice of many excellent accouch- 
eurs. The older authorities teach, and we believe with much 
force, — that, when the head lies in the pelvic cavity, the forceps 
should be applied in the diameter opposite to that occupied by 
the long cranial diameter, so that they will rest on the parietal 
eminences. Some later writers appear to prefer the pelvic mode 
of application even there, in adopting which the instrument will 



The Forceps. 617 

sometimes go to the sides of the head, but usually not. When 
free to choose between the two methods we do not hesitate to 
adopt the cephalic, inasmuch as it is always much less danger- 
ous to foetal life and features. 

In third and fourth positions of the vertex in the pelvic cavity, 
it is well to obtain our hold of the head, if possible, over the 
poles of the long vertex diameter, as we are then enabled nearly 
to finish the delivery before removing the blades. But in cases 
really demanding use of the forceps we frequently find this 
impossible, and are then driven to choose between an oblique 
and a lateral seizure of the head. In the latter case we ought 
always to prefer the cephalic mode, and carefully venture on 
forward rotation of the occiput. While there are many who 
denounce this procedure, we truly believe, after considerable 
experience of the practice of it, that it can be easily and safely 
adopted provided we pay strict attention to the pelvic anatomy, 
and the curves of the blades which we are using. Still, it may 
be safer for the unskilful operator to employ the pelvic mode, 
»and terminate the labor with the occiput looking towards the 
perineum . 

In enforcing forward rotation of the occiput with the ordi- 
nary forceps, a double application of the instrument is required. 
Owing to the pelvic curve of the instrument rotation can proceed 
only to a certain point before inversion of the instrument will 
begin, and this is a movement which greatly endangers the mater- 
nal tissues. It is inattention to this pelvic curve of the forceps 
which occasions the contusions and lacerations which some 
declare to be inseparable from the operation. 

When rotation has been carried to the safety boundary, then 
the blades should be carefully removed, by reversing the move- 
ment of introduction, and reapplied, this time with the concavity 
of the pelvic curve addressed to the foetal occiput. Rotation can 
then be completed and delivery safely effected. 

These directions apply, of course, with equal force to the 
termination of an occipito-posterior application begun above 
the brim. 

The Forceps in Face Presentations.— Application of the 
forceps to the face when it lies high in the pelvis is not permis- 
sible unless the chin is turned somewhat forwards, and the blades 
can be applied to the sides of the head. An application over 
the fronto-mental diameter of the face should never be made on 
a living child, as it means foetal death, and therefore, when the 



618 Labor. 

mental pole is not directed more or less forwards, the head lying 
at the brim, or above it if application to the sides of the head 
be impossible, the choice of operative resources, in case delivery 
is called for, should lie betwixt an attempt at conversion of the 
face into vertex presentation, and version. 

In mento-lateral, or posterior, positions, with the head in the 
cavity, or at the outlet, we believe the forceps may be used if 
necessary, and forward rotation of the chin effected. In fine, if 
the case seriously threaten to persist with the chin to the sa- 
crum, we believe it to be a conservative operation, for both 
mother and child, to apply the forceps, and, operating with ex- 
treme care, attempt to bring the part forwards. The author has 
so done in two cases, and that without harm. The instrument 
in that instance will require a double application, as in some 
cases of occipito-posterior positions. In the first application, 
the instrumental curve should look towards the forehead, and 
after rotation has been effected as far as the transverse diame- 
ter, the instrument should be removed, and reapplied with the 
curve directed towards the chin. Rotation is then to be slowly 
performed, during traction, and the chin brought to the pubic 
arch. 

In mento-anterior positions no unusual danger attends the 
forceps when they are applied to the lateral surfaces of the 
head. 

Use of the Forceps on the Breech.— Breech presentations 
are generally aided, when aid appears to be required, by instru- 
ments constructed for the purpose, namely, the blunt hook and 
the fillet. By means of these, properly applied to the flexure of 
the thighs, considerable force may be exerted and delivery 
effected. But when Ave come to compare them, in all their 
essential features, with the ordinary obstetric forceps, and reflect 
upon the respective uses of each, we discover that the latter 
instrument is much better suited to a, safe and easy delivery of 
the presenting head, than are the former instruments to a safe 
and easy delivery of the presenting breech. The fillet requires 
great effort and consummate skill for its application to a breech 
not within easy reach of the fingers ; and the blunt hook, while 
easily applied, is extremely liable to do serious injury to the 
fetal tissues. 

The ordinary forceps, though designed for the head, may be 
effectually and safely applied to the breech. Forceps of a pecu- 
liar pattern have been constructed for this purpose; but the 



The Forceps. 619 

common forceps (the short straight forceps being preferable, we 
believe) , when adjusted to the sides of the foetal pelvis, that is to 
say, over the poles of the transverse pelvic diameter, are equally 
harmless and efficacious. 

The author has made this use of the forceps in at least a 
dozen cases, and is well satisfied with the results obtained. 

From study, experience and reflection we have deduced the 
following conclusions : 

1. That the forceps may generally be used in breech presen- 
tations to better advantage than any other instrument, and 
with less danger than the blunt hook. 

2. As a preliminary to the operation, it is essential that the 
position be unmistakably recognized. 

3. The blades, when on, should embrace the pelvis over the 
poles of its trans verse diameter, as a much better hold is thereby 
acquired, and dangerous pressure with the points of the instru- 
ment by it averted. 

The Forceps to the After-coming Head.— This is an 
operation but seldom required, and it has been sufficiently 
described in another chapter. 



620 



Labor. 



CHAPTER XXI. 

MINOR OBSTETRIC INSTRUMENTS AND OPERATIONS. 

The Vectis. — The vectis, or lever, was devised by Roonhuysen, 
of Holland, about the time that the Chamberlens began to use 
the forceps in Great Britain. Roonhuysen handed down the 
secret to his sons and others, and it was eventually purchased 
byDrs. Visscherand Van den Poll, for 5,000 livres, and imparted 
to the profession. The instrument was long popular, but it has 
now fallen into comparative obscurity, not because of its in- 
trinsic worthlessness, but because it is eclipsed by the forceps. 
By some promiDent authors it is not even mentioned. 

The vectis greatly resembles a single blade of the straight 
forceps. Several patterns of the instrument are in use, a cut 



5HARP&5MITH 




Fig. 283.— Folding Vectis. 

of a very convenient one being shown in figure 283. 

Its Uses. — We believe that this instrument may be used to 
advantage in a number of unfavorable conditions, and since its 
employment does not necessitate the formalities of the usual 
instrumental delivery, less objection will be offered, and cases 
attended with few outward indications of abnormality may be 
greatly facilitated, which would otherwise be permitted to drag. 
Furthermore, the difficulties attending its use are not so great 
as those associated with the forceps, and hence the ordinary 
practitioner with a lack of skill which deters him from using the 
forceps, will be more inclined to avail himself of its aid. 

In many instances the forceps are said to be demanded when 
the difficulty and delay in labor has arisen from extension of the 
foetal head. The vectis is peculiarly well suited to just such 
cases, and when, by its simple leverage and traction, extension 
is overcome, labor goes on apace. When, in occipito-posterior 
positions, rotation is not disposed to take place in the desira- 
ble direction, the vectis is capable of affording much assistance. 



Minor Obstetric Instruments. 621 

and by it the occiput may be brought forwards. This is true 
also of the chin in those most trying mento-posterior positions 
of face presentation. 

The instrument acts as both lever and tractor. In exercis- 
ing its leverage powers we should be extremely careful not to 
make any part of the pelvic structures its fulcrum. Without a 
fulcrum its leverage action cannot be displayed, but it must be 
supplied by one hand of the operator, while the other acts upon 
the power arm of the instrument. A certain amount of traction 
may be exerted by the instrument as it is pressed firmly against 
the foetal head, but it is awkward and generally inefficient. 
Greater traction force can be applied when the fingers of the 
operator are made to take the place, though very imperfectly, 
of the second blade. 

The Blunt Hook. — This, like the vectis, is an ancient instru- 
ment, formerly much used for extracting the foetus in breech 
presentation, and occasionally in cephalic presentation attended 
with delay in delivery of the shoulders. It is intended to be 





Fig. 284.— Taylor's blunt Hook. 

hooked into the flexure of the thigh, or into the axilla, but it 
is so apt to injure the foetal tissues that, for the extraction of a 
living foetus, it has fallen largely into disuse. 

Hypodermic Injections —Though directions concerning 
the use of the lrypodermic syringe do not properly belong to a 
treatise on midwifery, yet, since the employment of hypodermic 
medication, and especially the sub-cutaneous injection of ergot, 
is herein recommended for certain conditions, and furthermore, 
inasmuch as some of our homeopathic remedies act much better 
when so employed, we offer the following hints : 

1. The best sites for puncture are the back of the arm, on a 
line with the insertion of the deltoid muscle, and the abdominal 
tissues near the umbilicus. 

2. The needle should be passed deeply into the tissues, so that 
its point will penetrate at least half an inch beneath the integu- 
ment. 

3. The fluid should be slowly injected. 
Catheterism— This maybe deemed scarcely worthy the title 

of an obstetric operation, and still in many cases its difficulties 



622 Labor. 

are such as to try the skill of even those of extensive experienoe. 
The variety of catheters which is best suited to obstetrical 
practice in general is the soft rubber, both because of its facility 
of introduction and its freedom from danger. The gum elastic 
and silver catheters answer the purpose, but best of all is the 
glass. 

Mode of Performance. — The catheter may be passed with 
a single hand, or with both. When both hands are used, the 
operator can stand by his patient's right side, and pass the 
fingers of his left hand between her thighs, as she lies with the 
limbs flexed, and locate the meatus, Avhile with the opposite 
hand the point of the instrument is made to engage. Or he may 
stand between the woman's feet, as she lies on her back, and 

pass the index finger 
of the left hand into 
the vagina but a short 
distance, with its pal- 
mar surface looking 
upwards. Now if the 
finger is made to lie 
flatly against the an- 
terior vaginal wall, it 
will rest on the urethra, 
while the meatus will 
lie close to the margin 

of the vagina, iust 
Fig. 285— Soft rubber Catheter. .w • ^ 1-u i 

within the vestibule. 

By remembering these points, introduction of the instrument 

will be greatly facilitated. With the soft rubber catheter now 

held in the other hand, between the thumb and forefinger, the 

point of it can easily be made to catch the meatus. If these 

instructions are followed, there is no occasion to attempt to 

locate the meatus with the point of the finger and thus render 

the effort more embarrassing and difficult. 

When a single hand is used, the catheter should be held as 
shown in Fig. 286, while the middle finger is made to rest just 
within the vaginal orifice, against its anterior margin, and the 
meatus will be found directly under the point of the catheter. 

It should be remembered that the meatus lies directly at the 
crown of the pubic arch, and as the middle finger of the single 
hand, or the index finger in the double hand operation, are 
pressed against the urethra as it lies in the anterior vaginal 




Minor Obstetric Instruments. 



623 



wall, they will easily feel the pubic arch, and thereby find further 
aid to introduction. Nor should it be forgotten that when the 
woman lies on her back, the catheter, in introduction, should be 
given a direction somewhat downwards and backwards. 




Fig. 286.— Manner of holding the Catheter. 

To perform catheterism skillfully requires considerable prac- 
tice, but, above all, thorough acquaintance with the anatomy 
of the external generative organs, and the details of the 
operation. 

To expose the parts, and locate the meatus with the eye, is a 
most indelicate and unnecessary proceeding. 



624 



Labor. 



CHAPTER XXII. 

OPERATIONS INVOLVING DESTRUCTION OF THE F(ETUS. 

Craniotomy. — Under the head of craniotomy are generally 
classed all the operations the performance of which involves 
mutilation of the head of the child. It is one of the oldest 
operations of midwifery, evidently having been practiced in the 
time of Hippocrates. 




Fig. 287— Thomas's Perforator. 

Its Sphere. — Craniotomy is employed in those cases of diffi- 
cult labor wherein neither the forceps nor turning can be effectu- 
ally adopted. It is also occasionally had recourse to (though 
not always wisely) in certain contingent accidents which happen 
during parturition, as in some cases of accidental and unavoid- 
able hemorrhage, in some cases of convulsions, in certain cases 
of uterine rupture, and in those cases of protracted labor in 




Fig. 288.— Blot's Perforator. 



which, from the neglect or ignorance of the physician in attend- 
ance, the pelvic organs and tissues are brought into such a state 
from pressure, that delivery by other means would be extremely 
hazardous to the life of the woman. It is also employed 
in difficult labor, when there is positive evidence of foetal 
death. 

Frequency of Employment. — From the statistics which 
follow it will be seen that the frequency with which this opera- 
tion is resorted to varies greatly among private practi- 



Destruction of the Fcetus. 



625 



tioners, hospital physicians, and the obstetricians of various 
countries. Dr. Collins reports that, during his mastership at 
the Dublin Lying-in Hospital, 16,414 women were delivered, 
during which time craniotomy was performed seventy-nine times. 
Dr. Joseph Clark reports that, in 10,387 cases of labor, crani- 
otomy had been performed forty-nine times. According to Dr. 
Churchill's statistics, British practitioners resort to craniotomy 
once in 219 cases; the French, once in 1,205% cases; the Ger- 




Fig. 289.— Blunt Hook and Crotchet. 



mans, once in 1,944%. Dr. Geo. B. Peck's homeopathic statistics 
show that craniotomy is rjerformed in one case out of every 879. 

The Perforator.— There are many patterns of perforators, 
but those illustrated in the accompanying cuts are among the 
best. The instrument ought to be well made, straight and 
strong. It is the first instrument used in performing crani- 
otomy, and, when properly constructed, can be employed with- 
out danger to the maternal tissues. 

In two cases where we found ourselves far from home with no 
expectation of meeting sucH an emergency, we used a bistouri, 




Fig. 290. — Thomas's Craniotomy Forceps. 



wound for half its length, for protection from its cutting edge, 
as a perforator, and then broke up the brain with a syringe 
tube and washed out the debris. 

The possibility of mistaken identity in connection with per- 
foration will be seen when we say that the sacral promontory 
has been pierced under the supposition that it was the foetal 
head. 

The Crotchet.— The crotchet is a hook, made of highly- 
tempered steel, possessing a sharp point, the design of which is 
fixation in some portion of the base of the skull, generally on 
its internal surface, by means of which traction may be made. 

(40) 



626 



Labor. 



For many years it was the only instrument used as an 
extractor after perforation. It is powerful in the hands of a 
skillful operator, but a highly dangerous instrument when em- 
ployed by the ignorant or inexperienced. All forms of the 
instrument are open to the serious objection of being liable to 
slip and wound either the maternal soft parts, or the hand of 
the operator, which should always be used as a guard. It has 
gone almost into disuse. 

Craniotomy Forceps.— This instrument is used for both 
extractive and destructive purposes. It is intended to lay hold 




Fig. 291.— Use of the Craniotomy Forceps. 

of the skull, one blade being passed within the cranium, and the 
other applied on the scalp. With the hold thus obtained, 
forcible traction can be made, and, save in cases of great pelvic 
contraction, delivery effected. 

In some instances, however, it becomes necessary after 
perforation, not only to break up and wash out the brain sub- 
stance, but also by these forceps to remove the cranial bones in 
fragments, before the bulk of the head is sufficiently reduced to 
enable it to be drawn through the pelvic canal. 

The Cranioclast — The cranioclast may be regarded as a pair 
of large craniotomy forceps, which admirably answer the pur- 
pose of delivery in many cases. The instrument designed by 



Destruction of the Fcetus. 



627 



Sir James Simpson is that most commonly employed in Great 
Britain. In America the cranioclast is not often used. It con- 
sists of two blades fastened by a button joint. The extremities 
are shaped like a duck-bill, and are sufficiently curved to give a 
firm hold of the head. The upper blade is provided with a deep 
groove into which the other sinks. 

The female blade is applied outside the head, and the male 
blade is passed through the opening made by the perforator, 
and then the cranial bones are all separately crushed by the 
forcible grasp of the instrument. This having been done, the 
cranioclast is made to take a final hold, when it is turned upon 
its long axis several times, thereby twisting the scalp, and ex- 
pelling more of its contents, after which extraction is easily 
effected. 

The Cephalotribe — In 1829, Baudelocque proposed a 




Simpson's Cranioclast. 



cephalotribe for crushing the cranium in labors obstructed by 
pelvic distortion. It was used in France and on the Continent, 
but was not adopted in England and America till a much later 
period. It is a large and powerful instrument, intended to grasp 
the head, crush it, and then to extract it. The instrument, as 
commonly constructed, resembles a strong pair of obstetrical 
forceps. It is suited to pelves distorted by rickets, rather than 
malacosteon, and hence should receive special favor from Amer- 
ican obstetricians. No rule can be given as to the amount of 
pelvic space required for its safe employment. 

Perforation is generally recommended as a preliminary step, 
though Baudelocque regarded the preservation of the integrity 
of the scalp as one of the advantages of his method. The blades 
of the instrument are applied after the manner of the blades 
of the long forceps in a high operation. Like the ordinary for- 
ceps, the instrument maybe applied through a partially dilated 
os uteri, when circumstances demand the operation under such 



628 Labor. 

conditions. In order that the base of the skull may be reached, 
the blades should be deeply inserted. When the blades are in 
situ, compression is gradually applied by means of a screw. 
As the diameters of the head are diminished in one direction 
they are increased in another, but, except in instances of 
excessive pelvic contraction, this is a matter of no great im- 
portance. 

If necessary the instrument may be carefully removed and 
applied so as to compress the head in its opposite diameter. 
Pajot claimed to be able to deliver through pelves contracted 
below two and one-half inches by thus crushing the head in 
different directions. 

Before beginning extraction, the aperture made by the per- 
forator should be examined to see that there are no projecting 
speculse of bone. 

Owing to the exceeding difficulty of making the cephalotribe 



Fig. 293.— Lusk's Cephalotribe. 

embrace the head in such a way above the superior strait as to 
enable the operator to crush the base of the skull, Tarnier has 
designed what is known as the basio tribe, which is practically 
a modified cephalotribe, or rather a combination of that in- 
strument and the cranioclast. One blade of the instrument acts 
as a perforator, by means of which the base of the skull is 
reached and the necessary hold obtained. 

With this instrument the involved diameters of the foetal 
cranium can be reduced nearly fifty per cent. 

Relative Value of the Different Methods of Reducing 
Cephalic Dimensions. — In those cases wherein reduction of the 
child's head is a manifest necessity, perforation may be prac- 
ticed and delivery then effected by means of the obstetric for- 
ceps. Should this instrument fail, delivery may be accomplished 
by means of version, the craniotomy forceps, the cranioclast or 
the cephalotribe. 

In suitable cases there is strong indication for the practice 



Destruction of the Fcettjs. 629 

of podalic version, before perforation, as a ready means of 
delivery. The advantages of this method are — 

1. The base of the cranium is more easily destroyed. 

2. The head is firmly fixed during perforation. 

3. The position of the head can be varied so that the 
eephalotribe may be applied over different diameters. 

4. The head having been crushed, the necessary traction is 
more easily applied upon the body and jaw of the foetus, and 
with less danger to the maternal structures. 

The relative merits of the eephalotribe and the cranioclast, 
as instruments with which to bring a mutilated child through a 
distorted pelvis, are not fully settled, but there appears to be no 
doubt that the cranioclast enables us to extend the limits of 
safe delivery far beyond what would be admissible with the 
eephalotribe, as by means of it we may, after partial or com- 
plete removal of the flat bones of the cranium, tilt the chin 
downwards, and draw the base of the head edgewise through, 
the conjugate diameter of the pelvis. 

It would be manifestly unfair to make a comparison between 
the Csesarean section. Porro's operation and craniotomy in 
general, since these laparotomy operations are not to be 
thought of save in those instances wherein craniotomy itself is. 
unusually difficult and dangerous. Through a pelvic conjugate 
contracted to two, or even two and a half, inches, craniotomy is 
attended with great danger and high mortality. Harris' latest 
tables show 153 Sanger-Leopold operations with a mortality 
of twenty-nine per cent., and 250 Cesarean operations with a* 
mortality of forty-six per cent. The percentage of deaths from 
the latter operation, however, during 1885-6-7-8 was only 
nineteen. 

Of 1 03 cases of craniotomy coming under the observation of 
Rokitansky, forty-one proved fatal. Under present antiseptic 
methods this mortality has been somewhat reduced, and yet 
the unfavorable results, in greatly contracted pelves, are sadly 
against the operation. 

Embryotomy.— This consists in mutilation of the foetus, 
with a view to reducing its bulk, in order to facilitate delivery. 
It may very properly include craniotomy, but, as it is not 
usually made to do so, we shall here follow the common division. 

Decapitation. — This operation consists in severing the head 
from the body, having done which, the latter can easily be with- 
drawn by means of the arm, and subsequently the severed part 



■■■H 



630 Labor. 

extracted. This is the operation to be preferred, in bad cases 
of impacted shoulder, if the neck can be reached without much 
difficulty. Many instruments have been devised for effecting 




Fig. 294. — Mode of using the Decapitating Hook. 

the purpose, but what is known as Ramsbotham's decapitating 
hook has met with much favor. To use the instrument it is 
slipped over the neck, and the part divided by a sawing 
motion. The most difficult part of the operation consists in 
getting the hook over the neck. To obviate this difficulty, 



Destruction of the F<etus. 



631 



some have recommended the use of a spring, with a string, 
which may be more easily passed. By the same means, or by a 




Fig. 295.— Applying the Chain of the Ecraseur for Decapitation. 



stiff male catheter, the chain of an ecraseur may be drawn over, 
and the head thus severed. 




Fig. 296.— Decapitation of the Foetus with the Ecraseur. 

In an emergency a strong pair of scissors may be made to 
pierce the neck and finally to sever it. 

The trunk is usually delivered without much difficulty. In 
most cases demanding decapitation the arm is prolapsed, and a 



632 



Labor. 



ready means for extraction afforded. Safe removal of the head 
may not prove so easy. It should be made to enter the pelvic 
canal in such a way that the exposed cervical vertebrae will not 
lacerate the maternal tissues. Delivery will usually be accom- 
plished by means of the forceps, the head being steadied at the 
brim, with the hand applied to the abdomen, while the blades 
are being adjusted. Firm compression reduces the cranial bulk 
by expressing the brain matter through the vertebral canal. 
Some prefer the cephalotribe, especially when there is much 
reduction of the pelvic diameters. 




Fig. 297. — Manual delivery of the Head after Decapitation. 

In case of extreme pelvic deformity it maybe found necessary 
to perforate the head and pulpify the brain in order still farther 
to reduce its bulk. 

Evisceration. — Our choice should rest upon the operation, 
in bad cases of transverse presentation, only Avhen decapita- 
tion cannot be practiced. In executing it the thorax is 
perforated at its most accessible point, and the opening 
made as large as possible, in order that the viscera may be 
removed, and the foetal bulk thus decreased. The perforator 
is swept about within the cavities, and the organs are thus 
broken up as much as possible, preparatory to their removal in 
fragments. The thoracic and abdominal cavities thus being 
opened, and to a great extent evacuated, the foetus should be 



Destruction of the Fcetus. 633 

made to perform an evolution, by means of which its pelvic 
extremity shall descend, and delivery thus be effected. Such a 
movement may be facilitated by division of the spinal column 
between the vertebrae by means of a stout pair of scissors, or 
even a knife carefully used, and then by traction with the 
crotchet, fastened internally on the pelvic bones. 

A number of cases have been recorded wherein neither decapi- 
tation nor evisceration could be successfully performed, and the 
operator was driven to the performance of the Cesarean 
operation. 



634 Labor. 



CHAPTER XXIII. 

OBSTETRIC LAPAROTOMY, LAPARO-ELYTROTOMY AND 
SYMPHYSEOTOMY. 

Gastro-hysterotomy, or the Osesarean Section, consists 
of abdominal and uterine incision with removal of the foetus 
through the openings thus made. 

The post-mortem operation was performed at a very remote 
period of antiquity ; but hysterotomy on a living woman was 
first practiced about four centuries ago. It subsequently be- 
came so common that a Dominican friar of the sixteenth 
century, ScipiaMerunia, was led to declare that it was practiced 
as frequently in France as blood-letting in Italy. 

This operation, which is regarded as one of the most formi- 
dable in the whole field of surgery, is an elective operation in 
those cases wherein the pelvic diameters are so obstructed or con- 
tracted as to render delivery per vias naturales more dangerous 
or absolutely impossible. 

The actual amount of contraction which calls for the opera- 
tion is not agreed upon by obstetricians, and it goes without 
saying that other factors besides the mere degree of pelvic con- 
traction enter into the calculation, as, for example, the skill of 
the operator and the facilities for the operation at command. 
Some competent obstetricians have deliberately rejected Cesa- 
rean section when the pelvic conjugate measured only one and 
a half inches, while others have regarded it wise to resort to 
the operation when the same diameter measured two and a half 
inches. 

The causes of death after the operation are hemorrhage, 
peritonitis, metritis, shock, septicaemia and exhaustion, being 
substantially those associated with hysterectomy. 

With the operation in general, America has furnished the best 
results ; while with the improved, or Sanger-Leopold, operation, 
Germany has shown the best record. 

The Operation.— The following most lucid account of the 
various steps of this comparatively infrequent operation is 
taken from Greig Smith's excellent work on Abdominal Surgery. 

" When it has been decided, in any given case, that puerperal 
hysterotomy is to be performed, the sooner it is carried out the 
better. The condition of the patient, already, in all proba- 



Obstetric Laparotomy. 635 

bility, not very favorable, rapidly deteriorates ; and the local 
effects of prolonged contraction of the uterine fibre, exhausting 
its vitality, are not conducive to subsequent healing. There- 
fore, though it is advisable to operate with a cleansed vagina, 
no time which delays operation is to be spent in doing this. 
Cleansing may be carried out after operation is over. The 
abdomen may be readily purified with carbolic or corrosive 
sublimate lotion, and particular attention must be paid to the 
umbilicus. Shaving adds to the security. The general arrange- 
ments for operation are the same as those already described 
for abdominal operations in general. 

" I should always use antiseptics in their fullest details. The 
instruments required are very few and simple. A scalpel, a pair 
of scissors, and a dozen pairs of lockiDg forceps, with the neces- 
sary complement of needles, sutures, ligatures, and sponges, 
are all that are wanted. Two long flat sponges will be found 
very useful. In every case we ought to be provided with a 
clamp and other instruments necessary for a possible hyster- 
ectomy. 

" The Parietal Incision. — The abdominal opening, which used 
to be made to one side of the median line, is now always made 
along it, and in the same manner as for ovariotomy. But the 
primary incision is longer, and does not descend so low, w T hile 
it rises higher. The elevation of the bladder renders it inadvis- 
able to approach within a distance of two or two and a half 
inches from the pubes. Above this point an incision of five 
inches may be made. According to the size of the patient, the 
upper limit will reach to, or pass a varying distance beyond, 
the umbilicus. According to Sanger, a suitable incision will in 
most cases be one-third of its length above the umbilicus, and 
two-thirds below it. The cut may go straight through the 
umbilicus ; but, for reasons given elsewhere, I think it is better 
that it should pass to the left of it. If, as some surgeons 
recommend, the uterus is to be turned out of the wound before 
opening it, then the incision must be made considerably longer. 
More will be said on this proceeding. The intention, in the 
operation to be described, is to give sufficient space — firstly, 
for removal of the child ; and secondly, for suturing the wound 
in the uterus. 

" Opening the Uterus, Extraction of Foetus. — In making the 
wound in the uterine w 7 alls, we have to bear in mind avoidance 
of hemorrhage and the encouragement of subsequent union. If 



636 Labor. 

the incision is carried too low, the branches of the uterine artery 
are endangered. The anterior reflexion of the peritoneum from 
the uterus is a good guide. Here the peritoneum is loosely 
attached and somewhat freely movable. The lower limit of the 
incision may enter this region. So far as bleeding is concerned, 
the upper limits of the incision are unimportant. The position 
of the placenta might be supposed to have an important influ- 
ence on the selection of the line for the uterine wound, but, 
practically, this would seem not to be so. Still, if it is possible 
to make out the site of the attachment of the placenta before 
incising the uterus (always difficult, often impossible, according 
to most writers), the operation might be rendered easier by 
avoiding this area. No extraordinary trouble need be taken to 
avoid it, however. A vertical incision is recommended. 

"The line of incision being fixed upon, two long flat sponges 
are placed, one on each side of it, between the uterus and the 
parietes. An assistant, standing on the left side of the patient, 
opposite to the surgeon, places a hand deeply into each flank 
behind the uterus, and makes the uterus bulge forwards into the 
parietal opening, firmly holding it there. By this manoeuver, 
and with the intervention of the flat sponges, the risks of 
escape of fluids into the abdomen are minimized. The uterus 
is so placed and fixed that the incision through its walls will 
correspond to the parietal incision. 

" As to the best mode of making the uterine incision, many 
opinions are held. Some recommend tearing; others, a com- 
bination of cutting and tearing; others, pure cutting. Some 
recommend a dissection deliberately carried out, each vessel 
being caught in forceps as it bleeds. To prevent bleeding, the 
placing of a temporary ligature around the neck of the uterus 
has been used by several surgeons; by others, equally trust- 
worthy, it has been neglected. As a matter of fact, the bleeding 
is rarely severe; but should it chance to be alarming, a sponge 
may be packed into the wound to check it while the elastic 
ligature is slipped over the uterus to its neck and tightened. In 
the absence of a proper tourniquet, a simple knot may be cast 
and tightened ; while it can easily be prevented from becoming 
undone by placing a catch forceps upon it. In every case it is 
best to do without the use of a constricting ligature, if that is 
possible ; every increase of traumatism adds to the danger. 

"I am in favor of a clean-cut incision. At the upper end of 
the projected incision, where the uterus is least vascular, an 



Obstetric Laparotomy. 



63T 



opening an inch in length is rapidly made by the scalpel. The 
opening need not completely perforate the uterine walls, but 
may be completed by pushing the finger through it. If the 
membranes are intact, a condition which is considered favorable, 
they need not now be divided ; but it can matter little if they 
are divided by the finger. The incision is now rapidly completed 
downwards, by scissors cutting on the finger as a director. A 
few seconds suffice for this part of the proceeding. The scissors 
is now thrown aside, and the hand plunged through the opening 
catches the head of the child, the fingers clipping the neck. If 




Fig. 298.— Delivery of Child. 



the feet are conveniently near, the child may be extracted by 
grasping them ; but as the uterine opening may contract round 
the following neck, it is better to extract by the head. If, 
during extraction by the feet, the head is caught in the uterine 
opening, the incision should be prolonged upwards to prevent- 
downward laceration of the uterine walls. 

"Uterine action will have been going on all this time, and 
gushes of amniotic fluid will have escaped from the uterus and 
run over the macintosh plastered round the abdominal opening. 
The assistant, meanwhile, will have carefully kept the uterus 
pressed forwards onto the abdominal walls: if he is skilled and 
attentive, no fluids will enter the abdomen. 



638 



Labor. 



"The umbilical cord is now divided between two pairs of 
locking forceps, and the child is handed over to an assistant. 
The surgeon then directs his attention to the detachment of the 
placenta, and the bleeding in the uterine wound. 

"If the uterus is contracting well, bleeding from the uterine 
sinuses soon ceases, and the placenta becomes spontaneously 
detached. At least one surgeon seems to have been able to 
increase the vigor of uterine contraction by the application of 
electricity, and this hint is well worthy of attention. A hypo- 
dermic injection of ergotine is advisable at this stage. If the 
condition of the patient permits of it, it is always best to wait 
for spontaneous detachment of the placenta. During this 
period it is easy enough to control bleeding from the uterine 




!% \\ 



Fig. 299. — Eemoval of Secundines. 

sinuses by compression by sponges, or, if necessary, by forceps. 
If, after a timely delay, the placenta is not detached, we may 
encourage detachment with the fingers ; but if the uterus still 
refuses to contract, and if bleeding continues free from the 
uterine incision, then we ought to proceed to hysterectomy by 
Porro's method. The secret of success in simple hysterotomy 
is efficient contraction of the uterus; if this fails us, the next 
best proceeding is hysterectomy. 

"In the great majority of cases, operated upon sufficiently 
early, the uterus contracts, the placenta is spontaneously 
detached, and the hemorrhage from the uterine sinuses spon- 
taneously ceases, or becomes unimportant. Careful attention 
is bestowed on the complete and thorough removal of the 
secundines. When the uterus is empty, it may be advisable to 



Obstetric Laparotomy. 639 

push a drainage tube or probang through the cervix and 
vagina, and leave it there to act as a drain. In any case, 
permeability towards the vagina will have been ascertained be- 
fore closure of the uterine wound is begun. There is little use in 
mopping out the uterine cavity; it soon refills. Generally 
speaking, the less manipulation the better: the process of 
parturition physiologically looks after itself; meddlesome inter- 
ference means, in many cases, harmful traumatism. 

"If the uterus has contracted well, and seems to be small 
enough easily to be pushed by the assistant through the 
parietal opening, there is no strong objection to this being 
done. It prevents the escape of blood into the cavity during 
the extraction of the placenta, and facilitates the insertion of 
sutures. Most surgeons would, however dread the risks from 
additional traumatism thus induced. 

" Closure of the Uterine Wound.— There is a very general con- 
sensus of opinion that on this detail, more than on any other, 
depends the success of Cesarean section. No doubt this is so. 
But many cases of recovery are on record in which no closure 
has been attempted ; the wound has been left to close by uterine 
contraction. On the other hand, it would seem that if uterine 
contraction fails, mere suturing is not always sufficient. 
Accurate suturing, plus uterine contraction, give the best 
results. 

" The problem is complicated. The natural involution of the 
uterus induces an atrophy of uterine fibres, which is degener- 
ative and attended with the free discharge of fluids. This 
process is, in wounds of uterine tissue proper, strongly preju- 
dicial to union by adhesive inflammation. Uterine contractions 
going on after delivery, mean that a condition of unrest exists 
in the uterine wound. This is another bar to union. And this 
unrest and the delayed union permit of the escape of intra- 
uterine fluids through the w r ound into the peritoneum — a con- 
tingency w T hich is full of danger. 

"The methods of suturing the uterine wound are very 
numerous. Lebas, in 1769, first introduced sutures. Polin, of 
Kentucky, in 1852, first introduced the silver suture; and this 
has always been a favorite material. Hemp, catgut, silk, and 
other materials, have been used; and the sutures have been 
placed in a great number of ways — deep, superficial, continuous, 
interrupted, singly, and in combinations. Wells, in a successful 
case, used a continuous silk suture, one end of which he carried 



640 



Labor. 



through the vagina, subsequently removing it by traction. But 
the success after any method was not encouraging. 

' k Within the past few years special attention has been 
devoted by several German surgeons to the mode of suturing 
the uterine wound, and with a success which is remarkable and 
striking. The extraordinary capacity of serous surfaces to 
become quickly glued together by inflammatory adhesions had 
been fully proved in abdominal surgery. In gastrostomy, 
enter otomy, and enterectomy, it had been shown that apposi- 
tion of serous surfaces, with fixation by suitable and numerous 
sutures, was followed by agglutination so intimate and strong 
that escape of fluids or gases was impossible. The 
danger in Csesarean section arose from gaping of 
the uterine wound, which took place from the 
natural shrinkage of the uterine fibre. As the fibres 
shrank the sutures became loose ; and they might 
even act as setons, encouraging the escape of 
uterine secretions. The principle of the new im- 
provement was, to look to the peritoneum for the 
perfect closure of the uterine wound towards the 
abdomen. 

"Though Van Aubel is said to have suggested 
this method in 1862, Sanger, who published his 
ideas in 1882,* deserves the chief merit of having 
introduced it. Leopold was the first actually to 
carry it out. Beumer, Obermann, Munster, Crede, 
and others soon followed; and the combined 
results of these operators, in the short time during 
which they have been working, have already 
placed the improved mode of Csesarean section by 
the conservative Sanger or Sanger-Leopold method 
ahead of all others. 

" Many variations in detail have been given. Sanger at first 
recommended resection of a wedge-shaped strip of muscular 
fibre under the peritoneal covering, so as to permit of the 
infolding of a greater amount of serous surface. This was 
found to be unnecessary, and sometimes even harmful. It is 
usually possible, without resection of muscular tissue, to fold 
inwards sufficient breadth of serous surface. It is unnecessary 
to recapitulate every variety of suture which has been em- 
ployed ; I select one which seems the best. 

* Der Kaiser schnitt, etc., Leipzig, 1882. 



Fig. 300 — 
Uterine In- 
cision closed 
by deep and 
superficial 
Sutures. 



Obstetric Laparotomy. 



641 



LT^L 



"A double row of sutures is used, deep and superficial. (Fig. 
300.) The peritoneal covering is detached from the muscular 
fibre for a little distance along the margins of the wound : in 
this way it is possible to turn inwards a greater surface of 
peritoneum. Then the deep sutures are placed. They are made 
to enter at about half an inch from the edge of the wound, 
passed obliquely through uterine tissue, and made to emerge 
near to the bottom of the cut surface. No suture should enter 
the uterine cavity. These deep sutures should be placed about 
three-quarters of an u 

inch apart ; and they 
should be carried, con- 
verging a little, be- 
yond the ends of the 
incision. 

"Then the super- 
ficial sutures are 
placed, two between 
each deep suture. The 
needle first pierces 
peritoneum and mus- 
cle, coming out a little 
below the lip of the 
wound; then it picks 
up the free edge of the 
peritoneum on its own 
side, and finally pur- 
sues the same course 
in opposite direction 
with the other side. 
The diagram, after 
Sanger, shows this 
more clearly than any description. The sutures are placed with 
great care, and they are carried a little way beyond the 
extremities of the wound. 

" The superficial sutures are first tied, bringing into accurate 
apposition two strips of peritoneum. Then the deep sutures 
are tied, causing still further incurvation of serous surfaces, 
and closing up and strengthening the whole. Finally, if appo- 
sition does not seem to be perfect, a simple continuous suture 
may be inserted over the whole. 

" In every case where future pregnancies may take place this 
(41) 




Figs. 301 and 302.— Diagrams to show the 
placing of Sutures in the Uterine Wound after 
Csesarean Section. P, peritoneum. F, uterine 
fibre. M, mucous or decidual layer. U, deep 
uterine suture. S, superficial serous suture. 



642 Labor. 

should be prevented by excising with scissors a small portion 
of each Fallopian tube. 

" While the sutures are being inserted, a few sponges placed 
in Douglas's pouch and around the uterus will absorb any 
fluids that may have escaped. These are now removed, and 
the whole cavity cleansed. 

"The wound in the parietes is sutured in the ordinary 
manner 

"The question of drainage is not without importance. In 
most cases it will be useless; but in some, by giving timely 
warning of the escape of uterine fluids, it may prove invaluable. 
At the worst it is harmless, and, therefore, I should always 
insert a drainage tube. It need not go deeply into the pelvis. 
A piece of rubber tubing, cut obliquely, laid over the uterine 
wound, and fixed by a stitch into the lower angle of the parietal 
incision, will suffice. At the end of a day or two it may be 
removed, should it not be required. 

"If the patient survives the shock of the operation, the chief 
subsequent danger is from peritonitis. This is treated accord- 
ing to ordinary principles by turpentine enemas and saline 
purges. But such peritonitis will almost certainly have been 
produced by extravasation of uterine secretions, and for this 
the best treatment is free drainage and frequent irrigation. At 
the same time cleansing of the vagina and of the cavity of the 
uterus by warm antiseptic fluids must be instituted. If there is 
evidence of gaping of the uterine wound, the abdominal incision 
may be reopened, and an attempt made to close it. If the 
patient will bear it, hysterectomy, even, might be contemplated 
as a last resource." 

After-care of the Patient.— The care of the patient after 
the operation differs in no essentials from that prescribed for 
laparotomy in general. 

Post-mortem Cesarean Section.— The Csesarean operation 
will also be advisable in those cases wherein women meet with 
sudden death during pregnancy or labor, and a living child is 
left in utero. There can be no reasonable doubt that many 
children have thus been saved who would otherwise have per- 
ished. The percentage of success in these cases, however, is not 
so large as we might be led to expect. Schwartz collected 107 
cases, out of which number not one child was saved. These, 
however, do not truly represent the chances which the opera- 
tion gives the child, for Duer has tabulated fifty-five cases, out 



Obstetric Laparotomy. 643 

of which number forty resulted in the delivery of living children. 
The lapse of time between the maternal death and the foetal 
extraction was as follows: "Between 1 and 5 minutes, includ- 
ing 'immediately,' and 'in a few minutes,' there were 21 cases; 
between 5 and 10 minutes, none ; between 10 and 15 minutes, 
13 cases ; between 15 and 23 minutes, 2 cases ; after 1 hour, 2 
cases; and after 2 hours, 2 cases." The last two cases did not 
long survive. These tables of cases may be justly regarded as 
representing extremes, and a fair estimate of success can be 
made only by drawing the mean between them.* 

"The reason that the want of success has been so great," 
eays Playfair, "is doubtless the delay that must necessarily 
occur before the operation is resorted to, for independently of 
the fact that the practitioner is seldom at hand at the moment 
of death, the very time necessary to assure ourselves that life 
is actually extinct will generally be sufficient to cause the death 
of the foetus. Considering the intimate relations between the 
mother and child, we can scarcely expect vitality to remain in 
the latter more than a quarter, or, at the outside, half an hour, 
after it has ceased in the former. The recorded instances in 
which a living child was extracted ten, twelve, or even forty 
hours after death, were most probably cases in which the 
mother fell into a prolonged trance or swoon, during the con- 
tinuance of w T hich the child must have been removed. A few 
authenticated cases, however, are known in which there can be 
no reasonable doubt that the operation was performed success- 
rally several hours after the mother was actually dead." 

The advisability of operating with the utmost dispatch in 
such cases has already been shown, but, since the maternal 
death was in some instances only apparent, the operation 
should always be performed with the same care and caution as 
if the mother were lining. 

Post-mortem Delivery Through the Natural Passages.— 
Mutilation of even the dead body is always to be avoided when 
nobody's interests will through it be promoted. This is espe- 
cially true in those cases of sudden death during labor, when 
the friends have been looking forwards to a successful issue of 
the parturient act. The laity in general do not look with the 

*" Probably the child -will survive the mother's decease longer, cseteris paribus , in pro* 
portion to the suddenness of the woman's death. If she lay sick for a considerable period 
prior to death, the amount of oxygen in the blood at the moment of dissolution is pre- 
sumably less than it would be at the instant of sudden death in a woman previously 
healthy." Dr. Underhill, vide Am. Jour. Obs., v. xi., p. 626. 



644 Labor. 

same degree of horror upon contused, as upon incised wounds, 
and should the case seem as hopeful for the child still in utero 
from delivery through the natural passages as through 
laparotomy, our choice of procedure should not be made with 
any hesitancy. Such cases, we opine, are quite exceptional, and 
with the os still unrelaxed, and the pelvic passage narrow, we 
should nob hesitate to use the knife upon the abdomen. 

In rare instances the chances for saving foetal life will be 
about as good by version as by abdominal incision. If labor 
has gone into the second stage before occurrence of maternal 
death, the forceps should be used without delay, when the pelvis 
is normal, in preference to the knife. 

There are a number of recorded instances of spontaneous 
expulsion after maternal death. 

Porro's Operation — Oophoro-Hysterectomy. — Briefly this 
consists in removal of the uterus and ovaries through abdomi- 
nal incision. It was first performed on a human subject by Dr. 
Horatio R. Storer, of Boston, in 1868, the patient dying 
sixty-eight hours thereafter. 

Prof. Edward Porro, of Pavia, on the 21st of May, 1876, 
having had encouraging results from the operation on some of 
the lower animals, had the courage to perform it on a woman 
with a rachitic pelvis measuring an inch and a half in the con- 
jugate. Both child and mother were saved. It has since been 
frequently performed with a mortality of about 28 per cent., 
and by some is now uniformly preferred to the Caesarean 
section. 

The operation has suffered several modifications, and has 
been somewhat simplified, especially by Tait, who gives the 
following account of it. 

"I believe that the operation which I advocate is simpler in 
its performance than the application of the long forceps, and 
that any man who could do the one could certainly do the 
other, as I propose to lay it down before you. Eviscerating 
operations are always of the most protracted and terrible 
kind, absolutely fatal to the child, largely destructive to the 
mother, and may possibly be fatal even to the operator him- 
self, who runs no small risk of injuring himself in the removal 
of the sharp fragments of bone. In advocating the perform- 
ance of abdominal section in such cases it becomes perfectly 
evident that simplicity must be the order of the day. We 
must have no rival incisions nor complicated kind of sutures, 



Obsteteic Laparotomy. 645 

but a simple, straightforward method of proceeding which 
may be understood by anyone and practiced by the least 
competent amongst us. You must bear in mind that in the 
abdomen containing a pregnant uterus the conditions must 
always be alike, and that therefore this operation will always 
differ from all other instances of abdominal section, where, 
almost without exception, variety is the order of the day. 

"It is practically impossible for every practitioner to be 
provided with all the numerous instruments which are wanted 
to make up the paraphernalia of the scientific obstetrician, 
while he would inevitably have at hand the few simple instru- 
ments required to perform the operation for which I am now 
arguing that it ought to be substituted for all the destructive 
and mutilating operations on the foetus in impacted labor. 
What is required, you may carry in your pocket case: two or 
three pairs of catch forceps for arresting bleeding points, a 
small sharp scalpel, two or three bayonet-pointed suture-needles, 
some silk, apiece of india-rubber drainage tube, and two needles 
of steel wire, and none better than the ordinary stocking knit- 
ting-needle can be found. 

"The first step in the operation is the abdominal incision, 
four inches in length, involving first the skin and then the 
muscles down to the sheath of the rectus, all of which ought 
to be divided by a sharp knife at one blow ; then the tendon of 
the one or other of the recti is opened, the muscular tendons 
fall aside, the posterior layer of the tendons is nipped up by two 
pairs of forceps and divided between them. The extra-peritoneal 
fat is treated similarly, then the peritoneum raised again by 
two pairs of forceps, a slight notch being made between them; 
and the moment this is effected air enters, and all behind falls 
away. No director is required, nothing but an observant pair 
of eyes, lightly applied forceps, and a delicately applied sharp- 
cutting knife. The finger is then introduced into the peritoneal 
cavity, and the relations of the uterus and bladder exactly 
ascertained. The peritoneum is then opened to the full extent 
of the four-inch incision, and the cut edges of the peritoneum are 
seized on each side by a pair of forceps and are pulled severally 
to the respective sides. No better retractors can be employed. 

"The piece of india-rubber drainage tube about eighteen 
inches or two feet long is now held as a loop between the fore 
and middle finger of the left hand, and is by that means slipped 
up over the uterus and pulled down over the cervix, passing the 



646 Labor. 

fingers behind the cervix to see that coils of intestine are not 
included in it. One hitch is then made on the tubing when it 
has been got so far down as possible, and it is pulled as tight 
as is consistent with safety. The second hitch may be made in 
it, but what is far better, an assistant keeps the tube on the 
strain, so that the one hitch will be quite enough to effect the 
most efficient clamping. 

"A small hole is then made in the uterus, just large enough 
to admit the finger ; if it is possible, the position of the pla- 
centa may then be ascertained; if not, the right forefinger 
follows its colleague, and between the two, by gentle rending, 
an aperture is made in the uterus, and the leg of the child is 
seized. The foetus is then carefully delivered feet first, and this, 
despite all the authorities to the contrary, is by far the best 
proceeding ; less blood is lost, and it requires but very gentle 
manipulation to relieve the head. 

"As soon as the foetus is removed the placenta is sought for, 
and removed similarly ; the uterus itself being then completely 
contracted by this time, is pulled out of the wound, and the 
elastic ligature is tightened once more, and finally arranged 
round the cervix, and the second hitch is applied. The main 
details of the operation are now completed ; all that is required 
is to pass the needles through the flattened tube and through 
the uterus, and out at the other side, forming a St. Anthony 
cross or two parallel parts to support the weight of the uterus 
and the stump, and to keep it outside the wound. A complete 
toilet of the peritoneum is then made, not forgetting the 
anterior vesical cul-de-sac; stitches are passed in the ordinary 
way to close the wound accurately round the uterine stump. 

"The uterus is now removed close down to the needles and 
strangulating rubber tube, so as to leave a little tissue above. 
It does not do to run any risk of the ligature slipping off, 
though this is hardly possible after the needles have been 
placed carefully through the structure of the tube. A little 
perchloride of iron is then rubbed gently over the surface of 
the stump; it is dressed with dry lint and some dry cotton 
gauze, an ordinary obstetric wrapper is put on, and the 
operation is at an end. The operation really takes very much 
less time to perform than it takes to describe, and as I have 
said before, because the details must always be the same as an 
operation in which there never can arise any unforeseen or 
unexpected difficulty." 



Obstetric Laparotomy. 647 

The operation as thus performed by Tait is quite simple, and 
may be undertaken, in emergencies, by anyone of surgical ex- 
perience, During our visit to this profoundly skillful operator 
a year ago, he had two cases of the kind, both of which did 
well. 

Comparison of Cesarean and Porro Operations. — "The 
best Porro record in Europe," says Dr. Robert P. Harris, "taken 
from its beginning, is that of Milan, under eight operators. 
The mortality in thirty-one cases has been 9, with only two 
children lost ; this makes the percentage 29 against 5 5-7 per 
cent, in Leipzig under coelio-hysterotomy. Vienna has had 
many more Porro operations than Milan, but lost 15 women 
out of her first 31. For the past four years, her unpublished 
record will show a much diminished death-rate ; that of Milan, 
during the same period, being far higher. We may safely rate 
this operation as having therefore a general average mortality 
of twenty-eight per cent. In the year 1887 there were 53 'new 
Cesarean ' operations, with 11 women and 4 children lost, or a 
mortality of twenty and four-fifths per cent. ; and in 1888, 
seventy-nine operations, losing 18 women and 3 children, or 
twenty-four per cent. The Caesarean record shows a decidedly 
lower average mortality in both the women and children than 
that of the Porro operation. Both are capable of a considera- 
ble reduction in the death-rate, but the exsection of the 
uterus must always add to the gravity of a Csesarean delivery 
in cases where this organ is sound and the child living. Where 
the child is dead and putrid, where the body of the uterus is the 
seat of fibroids, or where there are septic symptoms due to the 
condition of the uterus, the Porro-Caesarean method is to be 
preferred. In exceptional tumor cases, where exsection is not 
advisable, the tumor should not be removed." 

We should not forget, however, that for a successful per- 
formance of the new Caesarean operation much more surgical 
skill is required than for the Porro operation as simplified by 
Tait, and hence the latter, outside of large cities, is more likely 
to be followed by recovery. 

Laparo-Elytrotomy— This operation was brought promi- 
nently to professional notice by Dr. T. Gaillard Thomas, and 
is intended as a substitute, in some cases, for the Caesarean 
operation. It consists in making an incision from a point an 
inch above the right anterior superior spine of the ilium, with 
a slightly downward curve, on a line parallel to Poupart's 



648 Labor. 

ligament, to a point one and three-quarters inches above and 
to the outside of the spine of the pubis. In deepening this 
incision, the skin, the aponeurosis of the external oblique, the 
fibres of the internal oblique, and transversalis muscles are 
divided, and then the transversalis fascia, which is here dense 
and separated from the peritoneum by a layer of connective 
tissue containing fat. The superficial epigastric artery is 
divided and must be taken up. When the peritoneum is reached 
it is carefully raised without being cut, so as to expose the 
upper part of the vagina, through an incision in which the 
foetus is extracted. In incising the vagina there is great risk of 
hemorrhage. There is also great danger of cutting the bladder 
and ureter, and to avoid these the incision should be made 
nearly an inch and a half below the uterus, and in a direction 
parallel to the ureter and the boundary line between the blad- 
der and the vagina. The right side of the patient is chosen on 
account of the position of the rectum on the left. 

The operation has been performed but a few times, is not 
suitable to all cases, and, owing to its difficulties and special 
dangers, is not likely to become popular, hence we shall not 
here give at length its various steps. 

Symphyseotomy.— When the foetus is living, and the pelvic 
diameters are too contracted to admit of delivery by means of 
the forceps, the practice of obstetricians has been to destroy 
foetal life and deliver a mutilated body, or to resort to Cesa- 
rean section. There is now good hope that we shall not per- 
petually be driven to these dreadful alternatives, owing to a 
revival of the old operation of Symphyseotomy, first designed 
and performed by Sigault in the latter part of the last century. 
Since its revival the operation has been practiced almost exclu- 
sively by the Obstetric School of Naples, and by them is declared 
to be a godsend to humanity. The cleanliness of modern sur- 
gery may be the means of putting Symphyseotomy among the 
standard operations for dystochia due to pelvic contraction. 



PAET IV. 
THE PUERPERAL STATE. 



CHAPTER I. 
PHENOMENA AND MANAGEMENT OF THE PUERPERAL STATE, 

"The key," says Playfair, "to the management of women 
after labor, and to the proper understanding of the many impor- 
tant diseases which may then occur, is to be found in a study 
of the phenomena following delivery, and of the changes going 
on in the mother's system during the puerperal period. No 
doubt natural labor is a physiological and healthy function, 
and during recovery from its effects, disease should not occur. 
It must not be forgotten, however, that none of our patients 
are under physiologically healthy conditions. The surround- 
ings of the lying-in women, the effects of civilization, of errors 
of diet, of defective cleanliness, of exposure to contagion, and 
of a hundred other conditions, which it is impossible to appre- 
ciate, have most important influences on the results of child- 
birth. Hence it follows that labor, even under the most 
favorable conditions, is attended with considerable risk." 

Puerperal Mortality.— -A large amount of statistical infor- 
mation is at hand respecting the mortality of woman in 
parturition and the puerperal state, but it is largely from hos- 
pital experience, and, as is well known, does not represent with 
any degree of accuracy the results of private practice. Drs. 
Matthews Duncan and McClintock have both given us some 
valuable figures, derived from various sources, from which 
it would appear that in English obstetrical practice the death- 
rate is between 1 to 120 and 1 to 146. According to another 
report by McClintock, his estimate was increased to 1 in 100. 
We cannot regard this as a fair estimate of puerperal mortality 
in American private practice. From the data at our command 
We are inclined to put it at about 1 in 200. 

Phenomena Succeeding Delivery. These may be divided 
into the normal and the abnormal, and we will consider them in 

(649) 



650 



The Puerperal State. 



that order. The larger number of puerperal women includes 
those whose lying-in follows an uneventful course up to the 
hour of complete restoration, and it is our purpose herein to 
follow such a case briefly, so that it may stand in the mind of 
the young practitioner as typical. 

As soon as the excitemeut inseparable from the struggle and 
triumph of labor is over, the woman sinks into a delightful state 
of tranquillity of mind and body. At the same time she feels 
utterly prostrate from exertion, and somewhat stunned by the 
shock which parturition gives her sensitive, but patient, system. 
She is only languidly interested in what is now going on about 
her, and her enthusiasm can hardly be aroused. She is passive 
in the hands of her attendants. 

In a large percentage of cases a nervous tremor comes over 
the patient, which often proves distressing. It is unaccom- 





Fig. 303. — Pulse in a Primigravida. 
(After Barnes.) 



Fig. 304.— Pulse during Expulsion. 
(After Lorain.) 



panied by real chilliness, though it is more likely soon to termi- 
nate if the body be warmly covered. 

But these symptoms are short-lived, rapidly giving way to 
a lively interest in details, steadiness of nerves, warmth and 
moisture of the skin. The puerperal toilet once fully completed, 
and the child, after its bathing and dressing, laid beside the 
mother, drowsiness soon "steeps her senses in forgetfulness," 
and nature sets earnestly at work about her repair. 

The Pulse.— During pregnancy, as we have already said, 
certain important changes take place in the circulatory appa- 
ratus, in the vital fluid and in the nervous forces which govern 
them. In the blood, repeated examinations have disclosed a 
diminution in the number of red corpuscles, and an increase in 
the quantity of fibrin. At the same time there is a marked in- 
crease in the quantity of the fluid, somewhat in excess of the 
demands made by the augmented uterine vascularity. Other 
changes have been noticed, but they are of minor importance. 
This gives us then a plethora, so far as the mere quantity of 



Phenomena and Management. 651 

circulating fluid is concerned, but an anaemia with respect to 
the red blood globules ; while at the same time, and especially 
in the latter part of pregnancy, we have a condition of hyper- 
inosis. Consentaneously with the increase in quantity of blood, 
certain cardiac changes take place with a view to greater 
capacity and power. The heart cavities become slightly en- 
larged, and the ventricles somewhat hypertrophied. This con- 
dition was first made known by Larcher, in 1857. Cardiac, like 
uterine, hypertrophy disappears after pregnancy has ended ; 
but reduction is somewhat retarded by lactation. As the 
uterus augments in size, and the necessity for providing in- 
creasingly more oxygen for the foetus strengthens, the vessels 
become multiplied, both in number and size, until, at the close 
of pregnancy, this organ becomes truly cavernous, and con- 
tains a great quantity of the vital fluid. Meanwhile the woman 
has become a storage battery for the accumulation of nerve 





Fig. 306.— Pulse a few hours after 
delivery in a patient who had suf- 
Fig. 305,-Pulse immediately fered a P rofuse ' but not dangerous, 

after expulsion. (After Lorain.) hemorrhage. (Taken by Prof. Craw. 

ford.) 

force, so as to be well provided against the exhausting effects of 
a difficult parturition. 

Such changes as these have an important influence on the 
general circulation, which is exhibited to a certain degree in the 
radial pulse. Under these conditions in normal pregnancy, 
what characters should we expect to find in the pulse? First of 
all, we would look for a good degree of arterial tension ; sec- 
ondly, for ordinary frequency, and thirdly, for fair regularity. 
These are the very peculiarities which are ordinarily found. Dr. 
Mahomed was the first to call attention to these characteristics. 
Fig. 308 is that of a typical pulse in the non-pregnant 
state, and Fig. 303 is a presentation of the normal curves in 
pregnancy, between which we discover significant differences. 
In sphygmographic tracings the more marked the plateau at 
the summit of the first ascending stroke, usually the more pro- 
nounced is the arterial tension. Care must be taken, however, 
not to confound ordinary tension with the condition of athero- 



652 



The Puerperal State. 



matous degeneration which produces a somewhat similar 
tracing. 

After delivery, the condition in some respects is altered. The 
uterus, having been emptied, contracts and condenses so as in 
great measure to reduce the quantity of blood circulating within 
its walls. It is this firm contraction of the organ in normal 
cases which prevents post-partum hemorrhage. 

As the placenta is pushed off from the uterus by the shrink- 
age and contraction of the surface to which it is attached, 
solution of continuity involves many of the sinuses, which 
would in every case result in serious loss of blood, were not 
only the mouths, but also the entire calibre, of these vessels 
nearly, or quite, closed by the uterine contraction. What hem- 
orrhage we do have occurs chiefly during the interval between 
placental separation and expulsion, since thorough contraction 
cannot ensue while the uterine cavity is still occupied, even 




Fig. 307.— Pulse seven days after 
delivery. (Taken by Prof. Crawford.) 




Fig. 308.— Pulse of non-pregnant 
woman in health. (After Barnes.) 



though not widely expanded. Closure of these large uterine 
vessels creates considerable change in the circulation, which, for 
a few minutes, sometimes for a much longer peribd, is felt by 
the heart and larger vessels. The tumultuous effect is well 
shown in Fig. 305. Some blood is lost, but, in the average case, 
not as much as is now thrown out of the uterine circulation 
and forced into the systemic vessels. The result is increased 
arterial tension. 

These are rapid and important changes, and must produce 
manifest effects upon the pulse. Immediately after delivery 
there is pallor of countenance and diminished heat at the 
periphery, under which conditions, other things being equal, 
arterial tension would be further increased. 

Under these changed conditions, what sort of pulse should 
we expect to find? Certainly not a rapid and compressible one, 
but the very opposite ; and that is what we do find. Blot first 
called professional attention to the retardation and high ten- 



Phenomena and Management. 653 

si on of the early puerperal pulse. After labor it frequently 
goes as low as 55 or 60, and in some cases as low as 40 or 45. 
This it does in conformity with the law of physics which pro- 
vides for an in versed ratio of frequency and tension. This we 
may regard as the normal pulse at that period in puerperality. 
In some we find a different state of things. We have occasionally 
noticed, soon after delivery, a very rapid and feeble pulse, but 
chiefly in those cases where an anesthetic has been used to the 
extent of full narcosis. A similar state of the circulation is 
found after free hemorrhage; and, indeed, at such a time it 
would ordinarily be expected. However, the case from which 
Fig. 306 was taken, suffered a great loss of blood postpar- 
tum, and yet this tracing, taken on the same day, disclosed a 
pulse which, in the non-puerperal state, would be regarded as 
about normal in form and frequency. Other conditions and 
circumstances are sufficient to establish a similar state, such, 
for example, as expansion of the arteries in certain parts of the 

body, through action of the vaso- 
motor nerves. It may also occur 
from vascular excitement. Some 
have attached considerable sig- 
nificance to a deviation from the 
Fig. 309.— Pulse of same normal slow pulse of the early 
woman (Fig. 315) under ex- puerp eral state, claiming that a 
treme nervous excitement. • -, n ..-..,. £ , , , 

B rapid pulse is indicative of threat- 

ened hemorrhage. There is a rapid 
pulse following hemorrhage, but not necessarily preceding it. 
" These notes," remarks J. Ashburton Thompson, in the Obstet- 
rical Journal, volume V, page 285, "justify a contradiction of 
the bare assertion that a pulse which beats at or about 100 
shortly after labor prognosticates inertia of the uterus." In the 
same journal, volume VII, page 556, Dr. M. M. Bradley gives 
his experience with reference to this symptom in 300 cases, and 
says: "From these observations I am not inclined to attach 
much importance to the pulse rate, either as a sign of danger, or 
of post-partum hemorrhage." We notice that our good friend 
Dr. G. R. Southwick, of Boston, thinks otherwise, for he says in 
the Homeopathic Journal of Obstetrics, volume VIII, page 
176 : " A pulse remaining at 100, and slowly rising, is often the 
forerunner of hemorrhage." As an index of an enfeebled state 
of the general system, and hence of greater pr oneness to uterine 
relaxation, it may have some bearing on the prognosis. With 




654 The Puerperal State. 

a full, tense, and slow pulse, we should certainly consider the 
patient in less danger of post-partum hemorrhage. 

As the normal puerperium advances, the pulse becomes a 
little more rapid, and loses some of its tension. Ketardation 
and tension are not usually very marked after the third day, 
and, when their disappearance is deferred, we ought more atten- 
tively to watch our case. As late as the seventh day the pulse, 
in the case from which Fig. 307 was taken, still showed 
a very high tension. If the pulse loses these characteristics in 
a few days, and they subsequently return for a protracted 
period, the patient should be carefully watched for serious 
symptoms. 

Continuously increasing arterial tension usually signifies 
either a chill or a state of constipation, and calls for appro- 
priate treatment. Neglect of precautions may result in albu- 
minuria and eclampsia. 

Under the influence of the vascular excitement attendant 
upon the establishment of lactation, the pulse usually becomes 
frequent and soft. Vascular excitement and nervous excitement 
produce entirely different effects; the former diminishing, and 
the latter increasing, the arterial tension. 

Within the first few days following delivery, with the vascu- 
lar system unusually full, we can readily see what serious results 
would be liable to follow a sudden chill, a profound emotion 
and a variety of other occurrences. It is doubtless to this con- 
dition of the vascular system that inflammations involving 
vital organs owe their unusually fatal results. Taking the slow, 
ample, strong pulse as a typical one in the early days of the 
puerperal period, it behooves us, as careful obstetricians, atten- 
tively to observe and investigate deviations from it. We can- 
not afford to neglect the clinical thermometer, but we may be 
excused from using it at every visit, provided we attentively 
regard the pulse. Serious symptoms will not be found in pro- 
cess of development, nor in full bloom, without there being 
some indications of them in the pulse. Whenever at any visit 
a change is discovered, we should not fail to consult the tem- 
perature, and make such other physical examinations as will 
be likely to throw light on its causes. 

Post-partum Blood Changes.— The changes in the blood 
incident to utero-gestation, already described, have a decided 
influence over the puerperal state. The hyperinosis which 
already existed is now considerably augmented by the changes 



Phenomena and Management. 655 

i 

which follow delivery. The copious supply of blood which had 
been given the uterus is now turned into other channels, and 
the involution of the uterus, which now begins, throws into the 
circulation a considerable quantity of effete matter, to get rid 
of which all the excretory ducts are opened, and all the elimina- 
tive processes are set vigorously at work. These facts must be 
borne in mind as we advance in our study of the puerperal 
condition. 

Temperature— The skin, the activity of which was dimin- 
ished during gestation, now becomes functionally excited, and, 
in normal states, is always soft and moist, especially during 
the first week. Perspiration often becomes profuse without the 
development of any morbid symptoms, save a miliary eruption 
on different parts of the body, which may occasion some 
annoyance. A certain amount of perspiration in the puerperal 
woman is doubtless a salutary action, and an excessive degree 
of it may usually be prevented by keeping the temperature of 



Jrfcfe^b'^h H^HHH-^H^g^feD 



SHARP & SMITH 

Fig. 310. — The clinical Thermometer. 

the lying-in chamber from running too high, and forbidding 
the nurse to burden the patient with bed-clothing. 

During labor the patient's temperature is slightly elevated 
as a result of her strenuous efforts, and the strong perturba- 
tion of mind and body. It rarely goes above 100° F. and, after 
delivery, soon descends to normal or below. During the first 
few days after delivery the average temperature is slightly 
above that of perfect health. In strictly normal cases, there is 
no so-called "milk fever," though the temperature is liable to 
rise a degree or so during the stage of mammary engorgement, 
especially in galactorrhea. 

In women of sensitive, nervous organization, there is often 
rapid ascent and descent of the temperature. This movement is 
sometimes traceable to most trivial causes. It may be laid 
down as a rule that sudden elevation of temperature in puer- 
pera?, to a moderate height, should not be interpreted as indi- 
cative of impending serious disturbance, unless the movement 
be often repeated, or the elevation be maintained. 

The following diagram illustrates the temperature of a 
puerperal woman, taken morning and evening during the first 



656 



The Puerperal State. 



ten days following delivery, in whom no other unfavorable 
symptoms were manifested. In fact, repeated observations 
have satisfied the author that, in conditions which do not 
present any morbid symptoms whatever, among people in their 
quiet home life, the temperature of the body often attains a 
height of 100°. 

Uterine Involution. — The uterus, after delivery, tends to 
resume its original volume with astonishing rapidity. Though 
this change does not occur with uniformity and precise regu- 
larity, since various occurrences may serve to retard the action, 
yet we find that, in general, it observes the following course : 
Immediately after expulsion of the foetus the organ contracts 
firmly, and, as elsewhere stated, may be felt through the ab- 



DAY OF THE 

QISEASE 


1 


2 


3 


4 


5 


6 


7 


: 8 ' 


9 


10 


PULSE 


TEMP 


M 


E 


m|e 


M 


E 


M 


E 


X 


E 


M 


E 


M 


E 


ML 


U 


ft 


E 


M 


E 


95 
90 
85 
80 

75> 
70 


100 u 

o 
99 






i 
































































































































































/\ 




/• 








A 














*^s 


"S 


— W- 


^ 


s 


^ 


' < 


CZ: 


' ' 










\=- 




, 


V- 


£T 


— .j, 


■i 
o 
98 

•o 
97 

o 
-96 

95° 






v 1 
















•"- 














-\J 


r— 












































1 










































































































































































































































A 
























t\ 
























/\ 




































A 




/ 




A 
























y' 








/ 








1 








A 




' 


















V 




X-, 




i_ 


t 


l . 




s 












X 








IZ 








z£ 








ZC 


y~ 






^t 






* 






















X* 




































































* 






















, 



























































Fig. 311.— Diagram showing Temperature and Pulse Curves in a normal case. 

dominal walls, as a hard mass, like a cannon-ball. Alternate 
relaxations and contractions take place at intervals, and aid 
no doubt in the physiological process of involution. 

Extreme relaxation is a pathological state, and tends to the 
formation in utero of coagula, and in some cases permits 
profuse hemorrhage. The condition is also apt to lead to 
entrance of air into the uterine cavity, favoring decomposition 
and septic infection. 

During the first two or three days following the first condensa- 
tion the organ does not diminish much in size; but there- 
after reduction is usually quite rapid. At the close of the first 
week its fundus is found not more than one and one-half or 
two inches above the pelvic brim, and three or four days there- 
after it cannot be felt through the abdominal walls except by 
conjoint touch. In many cases uterine involution is arrested at 
about this point, and, as a result, the woman suffers from pelvic 



Phenomena and Management. 



657 



discomfort until the condition is discovered, and by appropriate 
treatment rectified. 

In normal cases complete involution is effected in six or 
eight weeks. The progress of uterine diminution is graphically 
shown by Heschl, from the weight of the organ at different 
periods. Immediately after delivery he found that it weighed 
22 to 24 oz.; in one week it was reduced to 19 to 21 oz.; at the 




Fig. 312. — Uterus of a Multipara at term. (Charpentier.) 

end of the second week it weighed 10 to 11 oz.; at the close of 
the third week it weighed 5 to 7 oz.; and in eight weeks its 
weight was but a little in excess of that which preceded the first 
pregnancy. 

Reduction of the uterus to its non-pregnant size usually goes 
on uninterruptedly, but, it may be impeded by too early rising, 
nonuse of the lacteal secretion, and laceration of the cervix 
uteri. 

(42) 



658 



The Puerperal State. 



After-pains. — Firm contraction immediately succeeds la- 
bor, and orderly involution of the uterus is commonly ac- 
complished without pain; but in some primiparae, yet more 




Fig. 313.— Inner surface of Uterus after delivery. (Coste.) P, placental 
site. S, uterine sinus. V, uterine veins. A, uterine arteries. E, round 
ligaments. 

especially in multiparas, the process gives rise to what has been 
significantly termed "after-pains." 

Khythmical* contractions of the uterus, as we have before 
said, take place throughout pregnancy, and parturition is but 



Phenomena and Management 659 

an intensification of them. After labor, involution is excited by 
a continuation of the same action. As these contractions are 
usually painless during pregnancy, so are they during puerpe- 
rality, complicating conditions alone rendering them painful. 
The presence in utero of coagula, with augmented uterine effort 
at expulsion, is the efficient cause of after-pains. They occur 
much more frequently in multipara than in primiparse, because, 
in the former, the uterine cavity is larger, and the rigidity and 
tonicity of fiber observable in primiparse has, in a measure, 
been lost. They are to a certain extent preventable, the 
prophylactic means being those which favor firm contraction of 
the uterus, among which abdominal pressure and kneading 
take a prominent place. The pains begin soon after delivery, 
and are recurrent, like those of labor. They are sometimes 
extremely severe. Application of the child to the breast, though 
a wise proceeding, increases the intensity of the after-pains. 

Their period of duration varies, seldom being protracted 
beyond two or three days. In some cases, after having disap- 
peared, they return for a time, and again leave after escape of 
a retained coagulum. They may be so severe as to extort 
cries, and are dreaded by many women almost as much as the 
pains of labor. 

After-pains should not be confounded with the pains ac- 
companying peritoneal inflammation, from which they may 
generally be distinguished by the absence of elevated tempera- 
ture, rapid pulse and abdominal tympanites and tenderness. 

The uterus sometimes appears to be in a condition of hyper- 
esthesia, wherein the intermittent contractions which charac- 
terize the puerperal state, unassociated with the presence of 
coagula, occasion much suffering. Dewees mentions a pain of 
frightful intensity which is experienced by some women in the 
lower part of the sacrum, and in the coccyx. It begins soon 
after delivery, and, unlike real after-pains, is continuous. We 
have never had our attention called to it. 

Treatment. — When after-pains plainly depend on the presence 
in utero of coagula, pressure judiciously applied to the fundus 
uteri, by expelling the uterine contents, sometimes affords relief. 
When of a neuralgic character, heat to the abdomen will be 
found agreeable and beneficial. 

There is no question that the prompt administration of 
arnica, after delivery, has a modifying influence upon this 
variety of suffering ; while, in some cases, it serves as an efficient 



660 The Puerperal State. 

prophylactic. Other remedies are often of great service, and 
some of the indications for their use here follow : 

After-pains extremely severe and long-lasting: aconite, nux v. 

After-pains too long, or too violent ; worse towards evening: 
Pulsatilla. 

After-pains too long and severe; though cold, she does not 
wish to be covered : secale. 

After-pains of a cramping nature, often attended with cramps 
in the extremities, especially in women who have borne several 
children: cuprum. 

After-pains worse in the groins ; over-sensitiveness ; nausea 
and vomiting : actsea rac. 

After-pains violent ; return when the child nurses : arnica. 

After-pains excited by the least motion, even taking a deep 
inspiration : bryonia. 

After-pains especially after long hard labor, spasmodic across 
the hypogastrium, extending into the groins : caulophyllum. 

After-pains very distressing, especially in women who have 
borne many children : cuprum m. 

After-pains violent in sacrum and hips, with severe headache, 
especially after instrumental delivery: hypericum. 

After-pains with much sighing: ignatia. 

After-pains with great sensitiveness of the abdomen: sabina. 

After-pains of a severe bearing character, as if everything 
were being forced out: belladonna. 

After-pains come and go suddenly : belladonna. 

After-pains very distressing, and the patient extremely 
irritable: chamomilla. 

After-pains which produce a desire to defecate: nux v. 

After-pains colicky, causing her to bend double: colocynth. 

After-pains producing faintness: nux vom., Pulsatilla. 

After-pains worse at night ; she wants the room warm, and 
must be well covered : rhus tox. 

After-pains accompanied with burning and bearing : terebinth. 

We have found caulophyllum most frequently useful ; it is to 
be avoided, especially in fluid extract or tincture, when there is 
too free a flow. 

The Excretions. — The activity of the skin has been pointed 
out. The urine also is secreted in large quantities, but difficulty 
in voiding it is often experienced on account of temporary 
paralysis of the vesical cervix, or from swelling and occlusion 
of the urethra. 



Phenomena and Management. 661 

The rectum is for a time inactive, a condition not at all in- 
imical to the woman's well-being at this particular period. 

Examination of the urine reveals a trace of sugar, varying 
in quantity with the volume of the lacteal secretion, being most 
abundant when the breasts are distended, or when, from any 
cause, the milk is not drawn. 

Changes in the Uterine Mucous Membrane— Without 
entering into a minute description of the post-partum changes 
occurring in the uterine mucous membrane, it will suffice to say 
that the inner surface of the organ is covered with coagulated 
blood, upon removing which we find a soft, moist, reddish-grey 
friable layer, covering every part, except that recently occupied 
by the placenta. Beneath this is the imperfect freshly formed 
mucous membrane. The deciduous layer does not extend into 
the cervical canal, but the latter is found filled with a free 
secretion of a glutinous, transparent, pinkish or bloody mucus. 

The placental site is elevated, and presents a mammillated, 
rounded, anfractuous surface, dotted over with coagula which 
are removed with difficulty. The walls of the venous sinuses, 
epecially at the placental site, are thickened and convoluted, 
and contain a small blood-clot, while their mouths are perfectly 
visible. 

From what Ave have just said it will be correctly inferred that 
the cervical mucous membrane is not exfoliated. During preg- 
nancy it is simply hypertrophied, and, after labor, the arbor 
vitse are discernible, though in a modified form. 

Vaginal Changes.— The vagina is shortened and diminished 
in caliber, the ruga? return, and the external orifice and vulva 
soon assume much their former appearance. A strong contrast 
is established between the conditions which are observed im- 
mediately after delivery and those observed at a little later 
period. 

The Lochia.— The discharges which escape from the vulva 
after delivery are known as the lochia. The period of their con- 
tinuance varies, but there is generally more or less discharge for 
three or four weeks. In some women, especially those who do 
not nurse, they run into a. bland leucorrhcea, which persists 
until menstruation returns. At first they are composed almost 
Avholly of blood, both fluid and coagulated. Clots of considera- 
ble size often accumulate in the uterus and vagina, especially 
in multipara?, and are discharged, with recurrent pains, during 
the first twenty-four or forty-eight hours. 



662 



The Puerperal State. 



After the first day, the lochia consist of about one-third 
part red corpuscles, while the other matters are chiefly white 
corpuscles, blood serum, numerous epithelial cells, and mucus. 
After the second or third day the red corpuscles almost wholly 
disappear. As soon as the lacteal secretion begins to be estab- 
lished, the lochia are greatly diminished in quantity, but soon 
again become profuse, accompanied with some blood, and later, 
pus corpuscles; but the blood usually disappears about the 
close of the first week. The discharge then continues, yellowish- 




Fig. 314.— Section of a Uterine Sinus from the placental site nine weeks 
after delivery. (Williams.) 

white in color, and of some consistency. At this stage it has 
been called the " green waters." 

The amount of flow varies widely. Instead of gradually 
diminishing, until final disappearance, it sometimes continues 
profuse for four or six weeks, without being accompanied by 
morbid symptoms. A persistence, or occasional recurrence, of 
a sanguineous discharge is generally indicative of irregular and 
imperfect progress of uterine involution. 

The odor of the discharges at times is quite offensive, even in 
those cases which present no other morbid symptoms. Such a 
condition, however, should always be looked upon with sus- 



Phenomena and Management. 663 

picion, since it may indicate retention of either some part of the 
secundines, or coagula in which putrefactive changes have 
been set up. The danger of infection may be diminished by 
carefully syringing the vagina, two or three times daily, while 
the offensive odor continues, with a mild antiseptic solution. 
The lochia are sometimes suppressed for an interval, without 
the occurrence of bad symptoms. In other cases morbid con- 
ditions begin to appear, which, if properly treated, will often 
be at once arrested. The following indications will be found 
valuable : 

Lochia suppressed by cold or emotion : actsea race. 

Lochia suppressed, head feels as if it would burst : bryonia. 

Lochia suppressed, followed by diarrhoea, colic and tooth- 
ache: chain omilla, caulophyllum. 

Lochia suppressed, violent colic : colocynth. 

Lochia suppressed, from anger or indignation: colocynth. 

Lochia suppressed, with tympanitic swelling of the abdomen, 
and diarrhoea : colocynth. 

Lochia suppressed by cold or dampness : dulcamara. 

Lochia suppressed from fright : opium, aconite. 

Lochia suppressed, with nymphomania: veratrum a. 

Lochia scanty and offensive: nux vom. 

Lochia scanty, becoming milky; heat, without thirst: Pul- 
satilla, stramonium. 

Lochia too profuse, with burning pain in uterine region: 
bryonia. 

Lochia profuse: millefolium, trillium, chamomilla. 

Lochia profuse, excoriating, protracted : lilium. 

Lochia milky, too protracted : calcarea, carb. 

Lochia long-lasting, thin, offensive, excoriating, with numb- 
ness of the limbs : carbo an. 

Lochia vitiated and offensive: lasts too long, or often 
returns : rhus tox. 

Lochia protracted ; great atony: caulophyllum. 

Lochia protracted ; drawing about ovaries ; discharge foetid, 
cheesy, or purulent : china. 

Lochia protracted, profuse, excoriating: lilium. 

Lochia acrid, foetid ; great prostration : baptisia. 

Lochia offensive, feels hot to the parts : belladonna. 

Lochia brown, foul smelling : carbo veg. 

Lochia very offensive and excoriating; repeatedly almost 
ceases only to freshen again: kreosotum. 



664 The Puerperal State. 

Lochia dark, very offensive ; scanty or profuse ; painless, or 
accompanied by prolonged bearing pain : secale. 

Lochia offensive, irritating : sepia. 

Lochia increased ; pain in the back when nursing: silicea. 

Lochia return when she first gets about : aconite. 

The Lacteal Secretion.— The mamma? for some time before 
labor are furnished with a variable quantity of a peculiar fluid 
known as colostrum, which contains a number of large granu- 
lar and fat corpuscles, and some milk globules. Within the first 
two or three days this is succeeded by the proper lacteal secre- 
tion, the establishment of which is sometimes attended with a 
slight acceleration of pulse and elevation of temperature, and 
also some restlessness and headache, which condition was for- 
merly termed the "milk fever." These phenomena generally 
disappear as soon as the secretion has beenw r ell established and 
the breasts properly cared for. The profession is rapidly com- 
ing to believe that "there can be little doubt that the im- 
portance of the so-called milk fever has been immensely 
exaggerated, and its existence, as a normal accompaniment 
of the puerperal state, is more than doubtful." Out of 423 
cases reported by Macan, in 114 there was no rise of tempera- 
ture. A number of recent writers on the subject refer the phe- 
nomena described to coincident septic influences; but, from 
careful observation, we are led to believe that the symptoms 
when present, owe their existence mainly to the irritation pro- 
ceeding from over-distension of the breasts. Decided relief is 
at once afforded by emptying them. 

The lacteal secretion does not make its appearance in every 
case. When, from any cause, a considerably elevated tempera- 
ture follows closely upon delivery, the milk may utterly fail to 
appear. Again, it would seem, as Dubois has remarked, that 
nature has left her work unfinished in some women. They are 
capable of becoming mothers, and are able to provide suit- 
able nourishment for their children throughout the period of 
gestation, but forever thereafter the latter is forced to lead an 
entirely independent phjT-sical existence. 

Therapeutics — Secretion Abundant. — Breasts greatly and 
painfully distended with milk : aceticum ac. 

Secretion too abundant: calcarea carb., uranium, Pul- 
satilla. 

Excessive flow of milk, causing great exhaustion : Phyto- 
lacca. 



Phenomena and Management. 665 

Secretion Deficient.— Milk scanty or absent ; despairing sad- 
ness : agnus c. 

Deficiency of milk with over-sensitiveness : asafcetida. 

Scanty secretion of milk : brjonia. 

Mammae seem distended, but milk scanty : calcarea carb. 

Little milk in mild, tearful women, presenting no morbid 
symptoms : Pulsatilla. 

Milk scanty or vitiated ; child refuses it : mercurius. 

Scanty milk, with debility and great apathy: phosphori- 
cum ac. 

The secretion is not established; stinging in the breasts: 
secale. 

Insufficiency of milk, or entire failure to appear : urtica urens. 

Quality of Secretion.— Milk watery and thin : calcarea phos. 

Milk thin, blue ; patient sad and despairing on waking: lach. 

Milk yellow and bitter, child refuses the breast: rheum. 

Pain in the back on nursing; increase of lochia; flow of 
pure blood. Complains every time the child takes the breast : 
silicea. 

Management of the Breasts in Non-nursing PuerpersB — 
When from any cause lactation is not performed, the breasts 
require most careful attention. They are liable to become 
distended, heated and painful, and, if not properly treated, 
inflammation and suppuration may ensue. 

We believe the best sort of general treatment for these 
patients is the expectant one. It is unwise to tamper with the 
breasts at all unless they become hard and painful. Meanwhile 
they should be kept warm by the application of a layer of cot- 
ton, over which may be spread a piece of oiled silk. If the dis- 
tension becomes excessive, it should be partially relieved by 
drawing only a small quantity of the secretion. If they become 
hard and lumpy the nurse should be instructed freely to apply 
warm oil and rub them in a gentle manner, always making the 
passes towards the nipple. If in any case inflammation begins, 
hot fomentations should be faithfully followed, until the pain 
and soreness disappear. A most excellent manner of applying 
the heat is to take a basin of sufficient size, and line it with two 
or three thicknesses of flannel wrung out of water as hot as 
can be borne, and then place it over the breast. By this means 
the heat can be retained for a long time. 

In certain cases we may think best to subdue the functional 
activity of the gland by the use of camphorated oil. We 



666 The Puerperal State. 

believe the use of belladonna plasters, as recommended by some, 
unwise practice, since it interferes with other, and more effective 
treatment. 

"The comfort of non-nursing puerperse will be secured," 
"says Dr. Geo. B. Peck, and their welfare enhanced by so sup- 
porting the breasts that their axes will deviate but slightly 
from the perpendicular to their bases. Whether simple slings, 
or a figure of eight bandage, or any other of the countless con- 
trivances that have been devised, is resorted to, is inconsequen- 
tial pro vided the desired result is obtained without annoyance 
to the invalid and without repressive action on the lactiferous 
system. The fame of a bandage used at the Boston (Mass.) 
lying-in hospital had reached my ears, but without details, so 
I called for information at the institution about a month ago. 
It is made of two strips of cotton cloth, each doubled and 
nicely stitched and then sewed together in the shape of the let- 
ter T, the horizontal strip being somewhat longer than the 
upright. Different sizes are kept constantly on hand ; for after 
use they require simply to be laundried, when they are nicer 
than ever. In the specimen I chanced to see, the length of the 
respective strips was apparently twenty-four and thirty inches, 
with a common width of about three and a half inches. 

"When used, a "bias'*' is taken in the horizontal piece 
exactly over the center of the upright and held in position by 
one or more safety pins, thus converting the letter into a Y. 
The size and style of the bias depends, of course, on the contour 
of the breast to which it is to be applied. The upright is now 
placed transversely across the back of the puerpera, the apex 
of the V portion coming just below, say the left axilla, and 
each arm extending respectively above and below the left 
breast. These are now drawn snugly in the direction of the 
right breast when their free ends are brought together on its 
axillary border, and there are securely pinned to the base of the 
upright. Finally the two arms are caught together at the in- 
termammary space by a large safety pin, thereby securing 
greater steadiness and support. Of course a few folds of cloth 
or cotton may be placed between the breast and the bandage 
in case of marked irregularity of contour, but generally the 
single band is amply sufficient. It will be noted that the effect 
of this simple device is to afford abundant support to those 
portions of the breast in which trouble generally originates 
without exerting compression : the result is that any excess of 



Phenomena and Management. 667 

the lactiferous fluid pours spontaneously from the nipple, and 
the liability of the ducts to occlusion is reduced almost infini- 
tesimally." 

Our therapeutical resources are but few. 

Camphora is most frequently used locally, but its action will 
be increased through internal administration. 

Belladonna has a very decided influence to diminish the 
lacteal secretion. While we deprecate the local use of the drug 
by means of plasters, because of interference with other local 
measures, we advise its exhibition by the mouth or by ointments 
applied to the mammae. 

Castor oil in cathartic doses, especially when the breasts are 
greatly engorged, appears to have a most salutary effect. 

General Attention to the Puerperal Woman.— The puer- 
peral patient requires plenty of fresh air, without exposure, 
wholesome food, quietude, and cleanliness. In warm weather 
the doors and windows should be opened often enough to keep 
the air of the room fresh and pure, while everything about the 
apartment which tends to contaminate should be scrupulously 
removed. The room selected for the confinement should not be 
near a water-closet, or bath-room, and should have no station- 
ary washbowl, as more or less foulness is emitted by all such 
connections with a sewer or cesspool. The bed should be placed 
so that the patient will not be in the line of a draft when the 
doors and windows are opened. In the cold seasons the temper- 
ature of the room should be kept as even as possible, at about 
65° or 70° F. 

It is assumed that the labor has been conducted with a strict 
regard to cleanliness, whether the details of antiseptic treatment 
have been observed or not. Great care ought now to be exercised, 
in order that our efforts in this direction be not rendered wholly 
inoperative by errors or ignorance of the nurse. The best of 
them will bear watching. Not long since I learned that it was 
a common practice of nurses at our own hospital to deposit, 
without washing, the syringe nozzle, after use, in the mouth 
of the bag, as a convenient manner of hanging up the long 
tube. 

After delivery, the soiled clothes should be drawn away, the 
vagina douched and the vulva washed. No subsequent douches 
ought to be employed unless the lochia become offensive. 

The woman should be encouraged to urinate within the first 
six hours, whether there be any inclination thereto or not. In 



668 The Puerperal State. 

the absence of special contra-indications she may sit up to do 
so if necessary. 

We do not deem it advisable to have a record of the pulse 
and temperature made by the nurse unless there are indications 
of a necessity therefor. Nervous, apprehensive patients are 
often done infinite harm by the words and demeanor of nurses 
who follow this practice. 

The Physician's Visits.— The puerperal condition is one in 
which sudden and alarming changes are liable to occur, and the 
physician should make his patient diurnal visits for at least 
three or four days. The interval between delivery and the first 
visit ought not to exceed twelve hours. 

At each visit during the first two or three days, in normal 
cases, in addition to the ordinary observations, the uterus 
should be examined by placing the hand on the abdomen, the 
temperature taken, and the urinary and lochial discharges 
inquired after. The condition of the breasts will also demand 
his attention. 

Retention of Urine.— This is one of the most frequent com- 
plications of the puerperal state, and occasionally proves to be 
one of the most annoying. 

The prudent accoucheur encourages his patient to keep the 
bladder empty during parturition as long as voluntary mictu- 
rition can be performed. 

This is not all, for it is hardly safe to put the utmost 
reliance upon the result of voluntary urination, since, even 
during parturition, there may be vesical atony resulting in 
partial retention. It is, therefore, wise to make careful palpa- 
tion and percussion of the hypogastrium to determine whether 
the bladder gives evidence of distension or of complete evacua- 
tion. In case of doubt, the catheter ought to be carefully 
passed. Having made himself sure of vesical non-distension 
up to a late moment in parturition, the bladder will receive no 
further attention until some hours after delivery. In many 
instances the woman experiences a desire to micturate within 
the first few hours; but in many other cases, ten, fifteen, or 
even twenty hours may elapse before the patient's attention is 
drawn by her feelings to the performance of this act. An effort 
is then made, which may prove utterly futile, and the patient 
find herself wholly unable to obtain relief. 

This condition of urinary retention is liable to occur after 
an ordinary case of labor, but it is oftener observed after deliv- 



Phenomena and Management. 669 

ery attended with extreme difficulty, and terminated either 
naturally or artificially. Still it is in only a certain percentage 
of instrumental deliveries that the complication is met. 

The etiological factors are here two in number: the one, 
extreme atony or partial paralysis, and the other, spasmodic 
contraction of the sphincter vesicae. The former is chiefly the 
result of dystocia, the bladder being constrained and somewhat 
crippled during pregnancy by extreme uterine distension, and 
finally overpowered by a tedious parturition. Spasmodic 
retention is sometimes a hysterical manifestation, but is oftener 
a result of irritation reflected from a torn vestibule or peri- 
neum. We are personally of the opinion that the great pro- 
portion of all cases of urinary retention find their immediate 
cause in vesical atony. 

It is a clinical observation that retention w T hich is not soon 
overcome is extremely liable to become prolonged, and may 
even annoy the woman until she is able to be about the room. 
We believe it never far exceeds these bounds. 

Treatment.— Every precaution should be taken to avert 
this annoying complication of puerperality. There is not much 
to be done, except to observe ordinary care in the general 
management of the case during parturition and the period 
immediately succeeding it ; but there are some things which we 
ought most scrupulously to avoid. What has impressed this 
truth forcibly on our mind is a case which we witnessed some 
time since, in which, a few hours post-partum, most injudicious 
treatment was adopted. The woman had passed through an 
instrumental delivery of considerable difficulty, and at the first 
visit, made a few hours thereafter, the excellent practitioner 
w T ho had charge of the case, assuming that there would be 
urinary retention, without giving the woman an opportunity 
to empty the bladder in a natural way, assured her that she 
would not be able to do so, and passed the catheter. The after 
history was in keeping with the assurance given, and artificial 
means for vesical relief were found necessary for a number of 
days. To be sure this patient might have failed to urinate if 
given the opportunity, and encouraged by a more favorable 
prognosis ; but we believe that retention is sometimes excited 
by unnecessary interference. This we regard as an example of 
meddlesome midwifery. Another important precaution to be 
observed is, to have the woman make one or repeated attempts 
to urinate within the first six or eight hours after delivery. 



670 The Puerperal State. 

We look upon this as a maxim of wise policy, inasmuch as dis- 
tension of the bladder is inimical to spontaneous evacuation. 
There are many women who find themselves absolutely unable 
to urinate while in the recumbent posture, who readily succeed 
when allowed to sit. It is accordingly our practice to direct, 
that, in the absence of decidedly contra-indicating conditions, 
the patient be permitted to assume the sitting posture if neces- 
sary, and we have not had occasion to regret the permission. 

There are certain remedies which, under these circumstances, 
are capable of lending considerable aid. 

Belladonna is one of the best of them, and is especially 
indicated in those cases where there has been small loss of 
blood, and the pulse discloses considerable arterial tension. 
Spasmodic retention is more likely to give way under this 
remedy than is retention due to vesical atony, although in both 
instances it may prove efficacious. 

Hyosciamus is indicated when there is lack of disposition to 
urinate, though there may be desire. Nervous and irritable. 

Camphor is also said to be a good remedy, but we have thus 
far observed no favorable effects from its use. 

Aconite is specially serviceable when the woman has exhibited 
good reaction from the strain of labor, attended with a 
moderately strong and rapid pulse. 

Arsenicum is sometimes effective where there is retention 
unaccompanied with desire to urinate. 

Nux vomica is indicated by frequent or constant desire and 
ineffectual effort. 

Cocaine. — Injection of a four per cent, solution into the 
urethra will often obviate resort to the catheter. 

The Faradic current has been found serviceable in some of 
these cases, especially those wherein the retention is attributa- 
ble to uterine atony. 

These are the only remedies which we now recall as having 
been in any degree serviceable in this affection. 

There are little expedients, such as the use of hot fomenta- 
tions and gentle kneading of the hypogastrium, that occasion- 
ally contribute to the effect sought, and are worthy of trial ; 
but, despite them and any other remedial agent at our com- 
mand, we are occasionally driven to conjure the aid of the 
catheter. 

This instrument, however, ought not to become our sole 
reliance; but remedies should be continued, and the woman 



Phenomena and Management. 671 

encouraged to make frequent, though not strong, efforts, at 
suitable intervals. In case of failure, the catheter should be 
introduced every six or seven hours, and the bladder thoroughly 
emptied. When we are driven to the use of this instrument for 
any considerable time, it is well, every twenty-four or forty- 
eight hours, to wash out the bladder with a mild antiseptic 
solution. 

Repeated use of the instrument is liable to set up urethritis, 
and therefore the operation must be performed with the most 
extreme delicacy. In the absence of a trained nurse, it is better 
for the attending physician to use the instrument. Still, an 
intelligent attendant, with a little instruction, can be made 
competent to pass it when the vulva is exposed. 

It goes without saying that this minor operation should not 
be performed in neglect of antiseptic precaution. Many nurses 
are grossly heedless, and require repeated injunction, and close 
surveillance. We are fully persuaded that serious results have 
many times proceeded from use of an unclean catheter. 

Regimen. — The regulation of the diet of lying-in women has 
been thoroughly revolutionized during the past few years. The 
older custom was to keep them on food of the lightest kind, 
given in small quantities for several days succeeding delivery ; 
but it has now become customary to prescribe a liberal supply 
of good nourishing food. There is danger, however, of running 
to an extreme in this direction, and thereby destroying the 
benefits which are derivable from a well-regulated regimen. Our 
best guide in the matter are the patient's feelings. If she has no 
appetite, it would be unwise to insist on a generous diet ; but, 
on the contrary, if the appetite is good, we may safely be gen- 
erous. Part of a cup of beef tea, a glass of milk, an egg beaten 
up with milk, or some toast may be given soon after labor. If 
there is a desire for it, a few mouthfuls of beef or chicken can be 
given after the first day. When lactation has become estab- 
lished, the restrictions on diet may be almost wholly removed, 
after cautioning the patient against overloading the stomach. 
Less care will be required in the case of robust women than in 
those who are delicate ; and, while we feed the latter well, w T e 
should be exceedingly careful about both the quality and quan- 
tity of their food. Stimulants should, as a rule, be avoided. 

The Bowels.— It is the custom in old-school practice to pro- 
voke a movement of the bowels on the second or third day, 
and, to bring it about, recourse is generally had to cathartics of 



672 The Puerperal State. 

various kinds. This we cannot but regard with disfavor, both 
in respect to the time of movement, and the mode of elicit- 
ing it. 

In the latter days, or hours, of pregnancy, there is generally 
a relaxed state of the bowels. When this is not true, an enema 
should be given in the early part of labor, and the rectum en- 
tirely emptied. This having been done, there is no crying neces- 
sity for further action during the succeeding four or five days, 
unless ineffectual desire is sooner manifested. On the fourth or 
fifth day a few doses of nux vomica may be given, and, if nec- 
essary, a full enema of tepid water and soap. If there is earlier 
desire, without favorable result, it will be wise, in the absence 
of inflammatory complications, to give a small enema. If the 
woman has been, or is, suffering from inflammatory action in 
the pelvic region, the regulation of the bowels will require most 
careful attention. 

In exceptional cases the bowels are diarrhoeic after delivery, 
the treatment of which condition will be but little modified by 
the puerperal state. 

Time for Getting Up. — Many women claim to feel as well, 
and almost as strong, immediately after labor as before, and it 
is impossible to impress them with the necessity for keeping the 
bed eight or ten days. It should be remembered, however, that 
this question of rest is the most important one in connection 
with either normal or abnormal lying-in. The experience of the 
laboring women of foreign birth, who generally get about on 
the third or fourth day, is pointed to by some as evidence of 
the harmlessness of the practice of early rising from the puer- 
peral bed. We admit that it is not so much the danger of 
immediately serious effects that we fear in such cases, as the 
weakness and derangements which are apt to ensue, and torture 
the patient for long months or years. And when we have an 
intimate acquaintance with the physical condition of those 
who disregard physiological laws respecting the lying-in state, 
whatever the nationality, we find that they are laden with 
ailments, and bear about with them the evil effects of their 
indiscretions. 

Still, the habit of keeping the woman on her back for a week 
or two following parturition, is a very injurious one. She 
should be allowed to sit upright to urinate and defecate, and by 
this means all coagula and retained lochia will escape from the 
vagina through force of gravity. 



Phenomena and Management. 673 

During the first few days the puerperal woman should be 
kept quiet, and free from annoyance. No garrulous neigh- 
bor should be permitted to disturb her repose of mind and body. 
She will do well to keep her bed for nine or ten days, no matter 
how strong or well she may feel ; and for at least a week subse- 
quently, more than half her time should be spent in a recumbent 
posture. If she will contentedly remain longer, so much the 
better, provided the nurse give her massage, as the normal post- 
partum changes will be more satisfactorily accomplished. In 
considering the question of rest after delivery, the fact that the 
uterus does not complete its involution under six or eight 
weeks, should be kept prominently in mind ; and it ought to be 
remembered that an early getting up is harmful largely because 
it interferes with the prompt and full accomplishment of this 
physiological process. 

There is but a single further caution to be offered in this 
connection, and that is to observe special care in the instance 
of feeble, nervous women, not to permit them to lie in bed too 
long. Some women require verily to be driven out of bed. 
Every little discomfort is magnified, and made a pretext for 
acting the part of an invalid. The management of such cases 
requires the most consummate discretion and tact. 

The temperature of the room in which the child is to be 
washed and dressed should not be below eighty degrees ; and as 
the comfort and well-being of the mother are not compatible 
with so great heat, these attentions should be given in another 
room. 

At the time of birth the child is covered with a layer, more 
or less thick, of vernix caseosa, which cannot be easily removed 
without first being treated to a thorough application of oil or 
lard. The bath should not be prolonged, and, at its close, the 
infant should be wrapped up warmly and laid aside for a time, 
or completely dressed. 

The condition of the navel after separation of the cord will 
depend in some measure upon the treatment of the cord at the 
time of birth. It is the practice of a goodly number of able 
practitioners to await cessation of pulsation in the cord, or 
not, and then sever it without applying a ligature. That the 
practice, if properly followed, is a safe one, w T e are fully satisfied 
from considerable experience. The cord should be held between 
the thumb and fingers and cut with a pair of blunt scissors. If 
bleeding follows, the stump should be held for a moment, and 

(43) 



674 The Puerperal State. 

then stripped between the fingers. As soon as bleeding has once 
ceased, the child may be considered safe. Still, like those cases 
wherein ligation is practiced, it is wise to examine the stump 
occasionally during the first half hour. While we do not recom- 
mend this innovation, we can see no rational objection to it. 
We have no question that it is more in accordance with physi- 
ological conditions, and is less liable to be followed by umbilical 
irritation and ulceration. 

When the child is being dressed, the stump of the cord should 
be rolled in antiseptic cotton, or laid between folds of iodoform 
gauze, and then covered with the band. 

Should the navel become inflamed, or severely irritated, we 
must enjoin perfect cleanliness, to be practiced without friction, 
and the application, if necessary, of iodoform or boracic acid. 

The child will require no nourishment but that which it 
derives from the maternal breasts. The early secretion — 
colostrum — has a laxative effect on the child's bowels, while at 
the same time it affords some nourishment. It is advisable, as 
a rule, to put the infant to the breast early, not only for its own 
benefit, but also for the good of the mother. 

In those unfortunate cases wiiere the mother is unable to 
nurse her child, or it is thought inadvisable for her to do so, 
we have to provide either a wet nurse, or an artificial diet. A 
discussion of this subject we shall omit, and refer the student 
to special treatises on the subject, and to works on diseases of 
children. 



The Puerperal Diseases. . 675 



CHAPTER II. 

THE PUERPERAL DISEASES. 



Phlegmasia Alba Dolens— Milk Leg.— The following: ac- 
count of this painful disease has been taken from a joint report 
on the subject made to The American Institute of Homoeopathy 
in 1889, the etiology, symptomatology, diagnosis and prog- 
nosis being from the pen of Prof. L. L. Danforth, M.D., and the 
treatment from that of C. G. Higbee, M.D. 

"The term Phlegmasia Alba Dolens has been employed to 
express a certain condition of the lower extremities observed 
most frequently in puerperse, but not wholly confined to them. 
This double title signifies, ety Biologically, a painful white 
swelling (inflammatory in character), and neither designates 
nor implies any information with regard to the chief etiological 
or pathological factors involved. It simply defines the disease 
in its essential features. In order that we may study the affec- 
tion from a nosographic point of view, this title merits preser- 
vation in medical nomenclature, for the present at least, with 
its primitive acceptation. 

" Etiology.— The theories which have been held from the 
earliest times with regard to the causation of this affection 
have been various, and, as is usual in the study of diseases 
which have been imperfectly understood, they have been as 
fanciful as numerous. Etiology has concerned investigation 
less than pathologj^. The trend of research has been toward 
the nature of the morbid processes in the affected part rather 
than towards the influences which have produced those 
processes. That we may ascertain the nature of the active 
forces which produce the ensemble of local phenomena which we 
designate phlegmasia alba dolens, it will be necessary to refer 
briefly, and in a very general way, to some of the most marked 
pathological conditions observed in this disease. This we do 
in order to define it in its essential features, and to trace, if 
possible, from this grouping of morbid processes, the predis- 
posing and proximate causes. In this we shall endeavor to 
avoid encroaching upon the province of the writer to whom 
pathology has been especially referred. 

"Mauriceau, one of the first to write intelligently on this 
subject, attributed the disease to ' a reflux on the part of cer- 



676 The Puerperal State. 

tain noxious humors that should have been evacuated by the 
lochia.' 

" Puzos gave a tolerably complete description of the disease, 
but considered it a sort of milk deposit, due to the arrest of the 
secretion of the milk, and its extravasation into the affected 
limb. Hence the term oedema lacteum and milk leg, by which 
the disease was and still is designated by many at the present 
time, particularly among the laity. 

"Mr. White, of Manchester, England, believed that 'the 
proximate cause was an obstruction, detention, and accumula- 
tion of lymph in the limb ; that the disease was local and had 
a local cause; that the obstruction was occasioned by some 
accident happening during the time of labor, or some state 
peculiar to childhood.' This accident he believed to be the 
pressure of the child 's head upon one or more lymphatic vessels 
to such an extent as to stop the progress of the lymph, and the 
vessel, being surcharged, at last bursts and sheds its contents. 
The lymph stagnating outside the vessels was, in his opinion, 
the cause of the symptoms. 

"Tyre, of Gloucester, maintained that the disease was an 
inflammation of the femoral and inguinal glands, due to press- 
ure during labor, or to the absorption of poisonous discharges 
from the vagina, or to inflammation commencing in a lym- 
phatic vessel and spreading upwards to its proper gland. The 
changes thus produced in the gland prevented the passage of 
fluid through it, and effusion into the cellular structure of the 
limb followed. (Ramsbotham.) 

"Dr. David Davis contended that the phlegmasia dolens de- 
pended on inflammation of the coats of the iliac and femoral 
veins, and in support of his essay presented the result of a dis- 
section of the veins in a fatal case in which the veins were found 
filled with coagula. This gave rise to the phlebitic theory, 
which was substantiated and rendered even more positive by 
the researches of M. Bouillard, ' which demonstrated that the 
femoral veins were diseased to a considerable extent, and their 
canals partially or wholly obliterated.' 

" Dr. Robert Lee, in 1823 (Ramsbotham), traced the inflam- 
mation into the uterine branches of the hypogastric veins. He 
believes that the disease was a true phlebitis, which began in 
the uterine veins, and thence extending, by continuity of tissue, 
to the common iliac, external iliac, crural and femoral veins. 
The comparative frequency of the affection in the puerperal 



The Puerperal Diseases. 677 

state Dr. Lee believed due to the open condition of the orifices 
of the uterine veins, at the moment of separation of the pla- 
centa, whereby ' a communication is indirectly established be- 
tween the venous system and the atmospheric air in a manner 
somewhat analogous to what takes place in amputations and 
other extensive wounds.' 

"The researches of Lee and Davis placed the phlebitic theory 
on a strong foundation and the name 'crural phlebitis' has 
been extensively adopted instead of phlegmasia dolens. The 
inflammatory theory was very generally received. Of late years, 
however, it has been indisputably shown by pathologists that 
the thrombus, which was always present to a greater or lesser 
degree, 'was by no means necessarily, or even generally, the 
result of inflammation of the vessels in which the clot was con- 
tained, but that the inflammation was the result of the coagu- 
lum.' (Play fair.) In the search for the true cause of phlegmasia 
dolens, and to prove or disprove the phlebitic theory, investi- 
gations were made, especially by Henry Lee (1852), which 
showed that it was very difficult to cause imflammation of veins 
by any irritant acting directly upon their lining membrane; 
that irritants act by causing the blood to coagulate in the veins. 

"Dr. Mackenzie (1861), of London, made most valuable 
contributions to our positive knowledge of this subject. He 
proved most conclusively, that 'inflammation of the veins in 
a pure and uncomplicated form cannot give rise to all the local 
and general phenomena of the disease, and cannot therefore be 
its proximate cause ; and furthermore, that phlebitis itself is 
for the most part not a primary, but a secondary affection, 
and in the great majority of cases is a consequence of the 
circulation of impure or morbid blood in the veins.' 

" The condition which predisposes to phlebitis is familiarly 
known as hyperinosis, or a state characterized by an excess of 
fibrin (or fibrinogen— fibrin-producing materials), and other 
extractive matters in the blood. This is the peculiar alteration 
of the blood observed in the cachexias and in pregnancy, as 
pointed out by the ha^matologists Andral and Gavarret. It 
consists in a change in the proportion of the elements of the 
blood. There is an excess in the amount of fibrin and serum 
and a deficiency of the blood-corpuscles, as compared with the 
normal state. In this condition of the blood there is a special 
predisposition to coagulation, which has been denominated 
inopexia (fibrin coagulation). When this tendency exists and 



678 The Puerperal State. 

the circulation is blocked by the formation of a clot in the 
vein, we have, as is well known, the formation of a thrombus. It 
is now known positively that the tendency to coagulation and 
thrombus formation is a constant phenomenon of phlegmasia 
alba dolens, and the other diseases characterized by occlusion 
of the peripheral veins. Here, then, is a predisposing factor of 
great importance in the production of this disease. But 
thrombus formation alone is not phlegmasia alba dolens. We 
have already ascertained that inflammation of the veins is the 
result of the coagulation within them ; that the coagulum is 
the primary factor, and that the inflammation is secondary 
thereto. The extent and severity of the phlebitis is variable in 
different cases. 

" Fordyce Barker maintains that phlebitis and phlegmasia 
alba dolens are separate and distinct affections. He refers to 
the number of cases of well-marked phlegmasia dolens, as 
reported by numerous observers, in which death occurred, and 
the veins were found perfectly healthy — devoid of inflamma- 
tion — notwithstanding the presence of the thrombus, as proof 
of the non-identity of the two affections. It would seem, 
however, in the light of more recent investigations, as if the 
difference was one of degree rather than of kind. But thrombus 
formation with or without phlebitis does not constitute, 
pathologically, all of phlegmasia dolens. The lymph channels 
are also affected, as evidenced by the enlargement of these 
structures, as well as the lymphatic glands, all of which are in 
many cases matted together by connective tissue. The exuda- 
tion of coagulable lymph when the part is pricked by a needle, 
the peculiar white, hard swelling of the limb, all tend to show 
that the lymphatics are choked, and can no longer perform 
their functions. 

"Dr. Tilbury Fox believes that obstruction of the main 
lymphatic channels is alone capable of giving rise to 'white 
leg/ and acts by preventing the removal of lymph from the 
affected limb. The obstruction in the lymph channels he 
believes may be the result of extensive pressure from tumors, 
thrombosis due to rapid compensatory absorption of morbid 
fluid, after sudden loss of any kind, or to inflammatory changes 
in the vessels themselves. It is unnecessary to pursue farther 
the study of the pathological processes present in this disease. 
By so doing we should be overstepping the limits which have 
been assigned us. We have brought forward the ideas of 



The Puerperal Diseases. 679 

different authors to show, first, thegreat discrepancy of opinion 
which has existed in times past with regard to the true nature 
of this affection : secondly, to express the belief that there is an 
element of truth in all the above theories. 

f, 'It is certain that venous obstruction and phlebitis exist, 
although they are secondary or tertiary features : that there is 
also engorgement of the lymphatics is now abundantly proven. 
If we interpret the theory of ' suppression of the lochia ' and 
'metastasis of milk" as implying arrest of secretion and excre- 
tion; and therefore the arrest of noxious material in the blood,, 
we recognize another true factor. 

;, 'The old pathology of the disease, as enunciated by 
Mauriceau and Puzos, was not. after all. so far from the truth. 
Their guess at the causes of the disease was more happy than 
the speculations of their successors. The old idea of poisonous 
material in the blood is. at the present day, included in the 
definition of the modern term, hypermosis. 

••'Having shown what the disease is in its essential features, 
it remains for us to seek the causes— predisposing and proxi- 
mate — which are capable of producing such a striking combina- 
tion of local and general symptoms. 

•'•'Among predisposing causes, conditions which favor blood 
coagulation are most important. This has been discussed 
sufficiently in the foregoing under the head of hyperinosis of 
the blood. But here we may very appropriately point out 
some accidents and complications of the puerperal state which 
have an important influence in increasing the tendency to blood 
coagulation in the venous system. One of the principal of 
these is hemorrhage, occurring either before, during, or after 
labor. Blood loss is always followed by increase of fibrin in the 
blood retained, and increase of fibrin favors coagulation. 
Again, feebleness of the blood current, whether from exhaustion 
following a tedious labor, or from hemorrhage, or from debility 
due to previous disease, favors coagulation. Great feebleness 
of the circulation, without syncope, may produce it. 

•"Some of the worst cases arise from septic infection. In 
addition to the state of the blood in pregnancy, disease-produc- 
ing germs are introduced from without, blood contamination 
occurs, and local inflammations result, involving veins and 
lymphatics, or the altered state of the blood may primarily 
produce coagulation in the veins. 

"Dr. Tyler Smith pointed out an occasional analogy between 



680 The Puerperal State. 

the causes of phlegmasia dolens and puerperal fever, evidently 
recognizing the dependence of the former on blood dyscrasia. 
'I believe,' he says, 'that contagion and infection play a very 
important part in the production of the disease.' In view of 
this he narrates the following instructive history: 'A short 
time ago a friend of mine had been in close attendance on a 
patient dying of erysipelatous sore throat, with sloughing, and 
w r as himself affected with sore throat. Under these circum- 
stances he attended, within the space of twenty-four hours, 
three ladies in their confinements, all of whom were attacked 
with phlegmasia dolens.' There is no doubt, at the present 
day, of the influence of septic infection in the production of 
this as well as other local inflammations, all of which may very 
properly be classified under the head of puerperal septic semia. 

"A recognition of this fact should have an important influence 
in regulating the practice of midwifery, so that this and other 
diseases of the puerperal period, which are dependent upon 
sepsis, may be reduced to the minimum. 

''Among the immediate causes may be enumerated those 
accidents and complications of delivery which render manual 
and instrumental means necessary to effect delivery. Thus the 
disease is apt to occur after placenta praevia, or after manual 
extraction of the placenta, inflammations about the pelvis 
following difficult obstetrical operations, complicated labors, 
multiparity, etc. In all these conditions the starting-point is 
an inflammatory process in the pelvic venous and lymphatic 
systems. In most cases, probably, a pre-existing lesion of the 
vein is the pathogenic cause, which arises from vitiated nutri- 
tion, cachexia, or some severe febrile condition. Another cause 
is the detachment of coagula from placental site, and lodgment 
in the crural veins, the clot or fragment having been floated 
along in the blood current. 

u Symptoms.— We shall describe two forms of the disease. 
The first is comparatively simple and free from danger. The 
second we shall call the infectious type. This is characterized 
by a marked dyscrasia, and is commonly fataL 

I. THE SIMPLE FORM. 

"This disease is one of the later morbid manifestations of 
the puerperal month. The period of greatest danger to the 
recently confined (from the third to the fifth day) may have 
passed without untoward symptoms. 



The Puerperal Diseases. 681 

"Suddenly, generally from the tenth to the twentieth day, 
the patient complains of pain either in the calf of the leg, the 
popliteal space, the thigh along the track of the femoral vein, 
or its principal branches. Sometimes the local symptom is 
preceded or accompanied by slight rigors, soon followed by an 
elevation of temperature to 100° F., and even to 103° or 104° ; 
the pulse increases with the temperature. Profuse perspirations ; 
a general condition of malaise and depression ; loss of appetite; 
furred tongue; pale face, and anxious countenance, are among 
the constitutional symptoms of the disease. In a few cases the 
local symptoms are unaccompanied by indications of constitu- 
tional disturbance. 

" The function of lactation is generally very much impaired, 
and sometimes wholly arrested, by the development of the 
disease. The lochial discharge seems, in many cases, to be very 
little influenced by the onset and progress of the disease, but in 
others it has been observed to become very foetid and offensive. 
With regard to the affected limb.it is usually the left which first 
becomes involved. Both legs may become affected, but it is 
never developed in the two simultaneously, although the interval 
between the involvement of the two legs is sometimes very 
short. The swelling, which soon follows the pain, extends from 
above downwards. This is a constant and one of the most 
prominent features of the disease. Trousseau declares that he 
has never seen the swelling progress in this direction (from 
above downwards), but that it always begins at the lower 
extremity and ascends towards the pelvis. 

"Prof. Barker is in accord with Bouchut and some others 
that neither assertion is absolutely correct, but that in some 
cases the swelling begins below and advances upwards, while in 
other cases the reverse occurs. Swelling is generally very 
marked, and the limb becomes twice its normal size. The skin 
is tense, of a glistening, shiny white aspect, and there is usually 
hyperesthesia of the surface. The swelling of the limb is unlike 
that of ordinary oedema. There is a sense of resistance on 
pressure quite different from the doughy feel of oedema, and 
there is not the pitting under pressure so characteristic of 
oedema; the impression made is quickly removed. Loss of all 
muscular power, complete immobility of the limb, is another 
characteristic of the disease. This is partly due to the pressure 
upon the nerves by the effusion, and partly to intra-pelvic com- 
plications. The patient cannot move the limb in bed; some- 



682 The Puerperal State. 

times there is loss of sensation, a wooden feeling in the limb. 
The enlarged cord-like sensitive veins may be seen and felt in 
some cases ; in others the most careful examination will fail to 
detect any such cords. Pain is produced by pressure in the 
groin and in the buttocks and thighs. Puncture of the tense 
white skin causes a drop of fluid to exude, which is thicker than 
serum and quickly coagulates. This fluid contains coagulable 
lymph, which the obstructed lymphatics could not carry off. 

" Internal examination of the pelvis will frequently reveal 
the complication with perimetritis, the constituents of the 
broad ligaments being the seat of inflammatory effusions. 

II. THE MALIGNANT OR INFECTIOUS FORM. 

"This form varies only in degree from that which has just 
been described. Robert Barnes says of this variety : ' When in 
subjects much depressed by previous illness, bearing some 
diathetic taint, who are reduced by hemorrhage and protracted 
labor, septic stuff capable of exciting thrombosis in fairly 
healthy subjects enters the uterine veins and lymphatics. The 
attempt to shut out the enemy by clothing does not succeed. 
The clots formed are soft, imperfect; the phlegmasia and 
lymphangitis spread ; suppuration takes place ; abscesses form 
in the perimetrium, or in the course of the femoral and iliac veins; 
the whole mass of the blood is invaded and further degraded. 
In this form the localizing power is lost; the poison breaks 
bounds ; it pervades every tissue in the body, and distant sup- 
purations may occur; it undergoes a change, partly chemical, 
partly necrotic. The course of these cases, to which the term 
"suppurative phlebitis and lymphangitis" of Cruveilhier would 
apply, is rapidly fatal. It is seen most characteristically in 
lying-in hospitals, or in that most disastrous conjunction, a 
lying-in ward in a general hospital.' 

"The disease is marked by sudden onset, high temperature, 
104° or 105° F., and rapid pulse, from 140 to 150 per minute. 
Great prostration, rapidly assuming a typhoid type ; delirium 
is a forerunner of death. Inflammatory affections of joints, 
ending in effusion of serous or sanious fluids, or pus is some- 
times met with. 

"Diagnosis. — The diagnosis of this affection is not difficult. 
The characteristic symptoms are so marked that they can 
scarcely be mistaken for those of any other affection. The 
sudden onset, the local pains, swelling, color 'of the skin, 



The Puerperal Diseases. 683 

immobility, evidences of venous inflammation, as shown by 
local tenderness and redness, and the involvement of internal 
veins, all point to venous thrombosis and lymphatic engorge- 
ment. 

"Prognosis. — In its simple form the disease usually termi- 
nates in recovery, although a favorable progress is sometimes 
suddenly checked by an accession of new symptoms, as well as 
a repetition of those observed early in the disease. These 
symptoms mark a fresh absorption of poisonous elements into 
the blood. The fever and more urgent local signs commonly 
subside in from one to two weeks. Swelling and impaired 
mobility last for some time longer. A degree of paralysis may 
last for several weeks. The whole process requires from a month 
to six weeks before complete recovery takes place. The absorp- 
tion of the effused lymph and serum and fibrous deposit takes 
time. The liability to detachment of fragments of the coagu- 
lum, the formation of an embolus, which may cause sudden 
death by occlusion of the pulmonary artery, should not be 
forgot teu. 

•'The prognosis of the septic form is very grave. Death 
commonly results. If the patient escape the immediate effects 
of the blood empoisonment, there is greater danger of embolism 
than in the simple form, on account of the marked blood 
dyscrasia. 

"Treatment. — In consulting, as I have, quite a large num- 
ber of books and journals in relation to the above subject, I am 
astonished at the small number of authors who have written 
upon obstetrics and gynaecology, who do an y thing more than 
refer to the disease in brief paragraphs. Some who mention it 
and speak of the uncertain pathology, give no treatment 
whatever . Others recommend treatment so irrational that no 
intelligent physician of the present day would think of recom- 
mending it. As it is conceded that the disease usually occurs 
in patients who are weakened by some other disease, the fallacy 
of the old practice of bleeding is apparent. Blisters, too, 
though more rational, by no means do as much good as harm. 
The swelling and congestion may produce an anaesthesia in the 
peripheral nerves, so that a blister will do great harm before it 
is felt. 

"The embrocations recommended by old-school authors 
were numerous, and no doubt useful in many cases. 

"I believe the best authorities agree that the disease is of 



684 The Puerperal State. 

septic origin. To us this would give the key to the curative 
remedies. While we have a long list for the relief of the most 
prominent symptoms, there are but few that correspond to all 
the manifestations of the disease. I think that in this disease, 
as in some others, the best treatment is that administered 
before they are attacked ; in other words, prophylactic. I find 
that many homoeopathic physicians have never had a case, and 
others very few. This corresponds with my individual experi- 
ence. As we have under consideration only those cases that 
arise during the puerperium, our recommendation will apply 
only to such cases. 

"As prophylactic, we should have our patients under super- 
vision during the whole period of gestation, and promptly 
check any departure from health at its onset. We should 
recommend such exercise in the open air as each can bear. This 
will give tone and strength to the muscles and nerves, that is 
so much needed at the time of confinement. Sitz baths taken 
every day, followed by gentle friction, are useful in equalizing 
the circulation and preventing congestions. If there is nerv- 
ousness and dread of the approaching crisis, gelsemium, given 
in the evening, will quiet the apprehension and induce sleep if 
there is insomnia. 

"If there is excessive pressure upon the superficial veins, 
bathe the parts with a lotion composed of arnica tincture, oil 
of sweet almonds and alcohol. In applying any external appli- 
cation, rub from the extremities towards the heart. These are 
the requisite means to use before confinement. 

"A few years ago I attended a lady in confinement, and left 
her in charge of my assistant while I went away from home to 
attend a meeting of this Institute. I had met the lady only 
once previous to the call for labor, and knew but little of her 
condition. About the end of the first week after confinement 
she was attacked with the first symptoms of phlegmasia, and 
it soon developed into a severe case. In answer to telegrams, 
I hastened home and had the satisfaction of conducting the 
case to a successful issue. In two subsequent confinements she 
had prophylactic treatment and no phlegmasia. 

"During labor every possible means should be used to pre- 
vent laceration of any of the organs involved, and to secure 
immediate contraction of the uterus after removal of the 
placenta, thus diminishing to the minimum the danger of 
absorption of septic poison or germs. 



The Puekperal Diseases. 685 

'•Corresponding to all the indications after successful deliv- 
ery, we know of no other remedy equal to arnica. It will do as 
much as any other to relieve the overtaxed muscles and soothe 
the nerves. 

"In case of lacerations, whether or not an operation has 
been necessary, arnica is still indicated. If septic absorption is 
feared, arsenicum album should also be given from the time of 
confinement. If premonitory pains are felt in the uterus and 
leg, the utmost care should be taken to secure rest, both 
physical and mental. The leg should be slightly raised and 
supported evenly, and be gently bathed with a solution of 
hamamelis. 

"The leg and foot should be kept warm, even to perspira- 
tion. If fever ensue, aconite should be given in place of 
arsenicum. Hamamelis internally will also prove a valuable 
remedy. If, in defiance of all this treatment, the disease pro- 
gresses, and the pain, swelling and fever increase, the leg may 
be enveloped in a thick layer of cotton batting, or wrapped in 
flannels wrung out of hot water, and frequently changed. 
Other remedies will have to be used as the symptoms change. 
Belladonna, rhus toxicodendron, apis, veratrum viride, in addi- 
tion to those above mentioned, will be at times useful. From 
the hour of delivery antiseptic vaginal injections should be 
used. Beef tea and wine will be needed to support the system 
until the crisis is past. 

"As soon as the inflammation subsides, bandage the leg 
evenly from the foot to the thigh. 

" If abscesses form in the inguinal glands or along the course 
of the lymphatics, freely open them and wash out the cavity 
with carbolized calendula water. To prevent the disease ex- 
tending from one side to the other, the patient should avoid 
any strain upon the leg not affected, and it should be frequently 
rubbed to promote circulation in the superficial veins. 

"If embolism develops, and the clots are transmitted to the 
heart or brain, a fatal termination is probable, and no rem- 
edies will avail." 



686 The Puerperal State. 



CHAPTER III. 

THE TUERPERAL DISEASES— Continued. 

Sudden Death During Labor and the Puerperal State.— 
Death sometimes occurs suddenly during labor and in the 
puerperal state, and may be attributed to a variety of causes, 
among which the following stand most prominent: 

Pulmonary Thrombosis and Embolism.— As we have before 
stated, the blood of a puerperal patient is in a hyperinotic 
state, and to that condition is justly ascribed the strong dis- 
position to coagulation which has been observed. "In all the 
accidents and anxieties of obstetric practice," says Meadows, 
"none can compare with the shock of the sudden death due to 
pulmonary thrombosis. A patient, apparently convalescing 
happily, is struck down with scarcely a moment's warning." 

This accident is sometimes due to detachment of vegetations 
from the cardiac valves, but oftener, as has been intimated, to 
a general blood dyscrasia, which predisposes to coagulation. A 
clot may form on the right side of the heart, and extend to the 
pulmonary artery, the coagulation, it is said, taking place sud- 
denly. The patient appears to be doing well, when upon mak- 
ing some exertion, it may be but raising the head, profound 
dyspnoea is suddenly developed, accompanied by most frantic 
efforts to breathe, and the utterance of faint cries, soon fol- 
lowed by syncope and death. It is liable to occur not only 
during the period immediately succeeding delivery, but even 
after the woman has begun to walk about. 

It is plain that but little room is given for treatment in such 
desperate cases. About all that can be done is to keep the 
patient as quiet as possible, and if life be prolonged, with 
chance for recovery, stimulants should be carefully exhibited. 

Syncope. — After excessive loss of blood, the heart, under the 
strain of sudden exertion, is liable utterly to fail. In such cases 
death takes place almost instantaneously. For days, and, in 
extraordinary cases, for weeks after delivery, it is advisable to 
keep women who have suffered from exhausting hemorrhages 
under the greatest restraint, as a very slight over-exertion is 
in some instances fatal. 

Whenever a woman faints in the puerperal state it is highly 



The Puerperal Diseases. 687 

important that she be relieved as speedily as possible, for there 
is here a double danger— that of utter cardiac failure, and that 
of retardation of the circulatory currents giving rise to coagu- 
lation of blood, and the occurrence of fatal thrombosis or em- 
bolism. We should indulge in the free use of diffusible stimu- 
lants, and the immediate application of a sinapism to the 
precordial region. 

A remedy may be selected from among the following: 

Pulsatilla. — This mild remedy acts nicely when the patient is 
of a mild, tearful disposition, and has shown great sensitiveness 
to every impression. 

Veratruni alb.— When the attacks come on suddenly and 
are repeated on the least exertion. Coldness of the extremities. 

China.— Especially if there has been much loss of blood. It 
is a good remedy, however, when there has been no unusual 
blood loss, but there is low vitality, weak digestion and sensi- 
tiveness to the cold. 

Phosphoric acid. — This remedy is especially serviceable when 
the woman has been in poor health for some time prior to labor, 
and is of a weak, nervous, brainy organization. 

Amyl nit. by inhalation should be thought of as an early 
aid, and its good effects may be prolonged through administra- 
tion by the mouth. 

Cactus grand, is especially of use when there is great sensi- 
tiveness of the nervous system, weak digestion and tendency 
to palpitation of the heart. 

Digitalis stands forth prominently as one of the most useful 
remedies whenever there is weak cardiac impulse. We purposely 
refrain from putting it early in the list, as its use has become 
routine, and we believe much better effects may be obtained from 
remedies indicated by particular symptoms. 

Entrance of Air Into the Veins.— McClintock cites six 
cases in which death appeared to be due to the entrance of air 
into the veins. Madame Lachapelle mentions two, and others 
have been reported. When firm uterine contractions do not 
follow delivery, the uterine sinuses are left in a condition favor- 
able to the entrance of atmospheric air. In one of Madame 
Lachapelle's cases it was found that the "uterine sinuses 
opened into the interior of the uterus by large orifices through 
which air could readily be blown as far as the iliac veins, and 
vice versa." The very action of the uterus itself in contract- 
ing and expanding, would have a tendency to draw air into the 



688 The Puerperal State. 

sinuses, since, at the moment of expansion, relaxation of the 
vessels and the entrance of a certain amount of air into the 
uterine cavity are coincident occurrences. 

Pathologists are not in accord with regard to the cause of 
death in these cases. The reasonable theory is that of Virchow, 
Oppolzer and Feltz, which refers the fatal result to impaction 
of air globules in the lesser divisions of the pulmonary 
arteries, where they constitute gaseous emboli, and produce 
death in the same manner as the fibrinous emboli. To this 
cause we may probably justly refer a considerable proportion 
of all cases in which sudden death occurs soon after delivery. 
The symptoms do not correspond to those of shock as ordi- 
narily manifested. 

Violent Emotions. — Violent emotions of grief, fear and 
anger are responsible for a small percentage of sudden deaths 
during the puerperium. 

It is possible that, in some cases, timely relief may be afforded 
by our remedies ; but death in these instances is often instan- 
taneous. 

Colocynthis. — Complaints arising from anger. (Also staphi- 
sagria, belladonna, ignatia, chamomilla, cistus and platina.) 

Gelsemium. — After bad news. 

Aconite. — After fright. (Also ignatia, opium, belladonna, 
coffea, lachesis and Pulsatilla.) 

Ignatia. — After grief. (Also phosphoric acid, aconite, staphi- 
sagria, colocynth, lachesis.) 

Organic heart lesions, recognized or unrecognized, are 
among the common causes of sudden death during the puer- 
peral state. 

Defective Lacteal Secretion.— Many women, especially 
those who possess a nervous temperament and are poorly 
nourished, are annoyed by having an insufficient quantity of 
milk to supply- their babes. 

We believe the practice adopted by some physicians, who 
recommend the use of alcoholic stimulants in some form for the 
purpose of overcoming this embarrassment, is pernicious to 
both mother and child. Outside of the suitable homoeopathic 
remedy, our main reliance in such cases must be a sufficiency of 
good nutritious food, especially such as contains phosphatic 
elements. Yet such mothers should never eat to repletion under 
the stimulus of a desire to provide nourishment for their young, 
as the result of such a practice is almost sure to be unpleasant. 



The Puerperal Diseases. 689 

The article of food which in our experience has proved the most 
satisfactory, is fresh milk. Women of delicate nervous organi- 
zation will sometimes thrive on it, while at the same time their 
supply of milk is greatly augmented. In exceptional cases it 
does not agree. 

The remedies most useful to increase the lacteal secretion 
are the following : 

Scanty secretion, with despairing sadness: agnus cast. 

Deficiency of milk, with over-sensitiveness : asafcetida. 

Scanty secretion of milk : bryonia. 

Scant} r secretion of milk in women of a scrofulous diathesis : 
calcarea carb. 

Mammae distended, but milk scanty: calcarea carb. 

Little milk, in mild tearful women in apparent health : Pul- 
satilla. 

Milk scanty or vitiated ; child refuses it : mercmius. 

Scanty milk, with debility and great apathy : phos. ac. 

Lack of milk, with much stinging in the mamma? : secale. 

Insufficiency, or entire lack of milk after parturition: urtica, 
urens. 

We often effect most good in these cases when we direct our 
remedies against the constitutional dyscrasiae observed in our 
patients. 

Depressed Nipples.— When the nipples, instead of being 
prominent and full, are depressed, or retracted, the child expe- 
riences the utmost difficulty in nursing, and on this account 
may, from the start, utterly reject the breast. 

In some of these cases the depression is due to anatomical 
defects, and cannot be overcome ; but in others it is the result 
of pressure, and by manipulation and suction it is soon suffi- 
ciently overcome for functional purposes. If the defect cannot 
be remedied, a glass nipple shield, with rubber tube, will often 
afford a satisfactory medium through which the child may 
nurse. 

Excessive Lacteal Secretion. — This is known as galactor- 
rhcea, and sometimes seriously interferes with successful lacta- 
tion. It is not alone women of robust constitution who are the 
subjects of excessive secretion of milk, but the weak and deli- 
cate as well, in whom, of course, it is a condition of greater 
import. In the former the secretion may be wholesome, but in 
the latter it is generally watery and innutritious, and, unless 
the morbid condition be corrected, serious effects upon the 

(44) 



690 The Puerperal State. 

health are likely to be produced. The woman begins to suffer 
from weakness, emaciation, insomnia, headache, and a host of 
other unpleasant symptoms, and is finally forced to relinquish 
nursing. 

Galactorrhea is in a measure under the control of remedies, 
and the effect of these should be tried before depriving the infant 
of the maternal breast. Those from which the greatest benefit 
is likely to be derived are, calcarea carb., uranium, Pulsatilla 
and Phytolacca. 

If the mother is unwilling to wean her child, certain remedies 
may be administered with salutary effect on her physical condi- 
tion. For the general weakness and prostration which she suf- 
fers, china, calcarea phos., phosphoric acid, and carbo veg. are 
the most useful. 

The following remedies may aid in correcting the quality of 
the secretion : 

Calcarea phos.— Milk watery, and the woman of a phthisical 
build. 

Lachesis. — Milk thin and blue and the patient sad and 
despairing on awaking. 

Acetic acid. — Milk impoverished, bluish, of strong sour odor 
and taste. 

Arsenicum. — Milk poor in quality and the woman fleshy. 

Sulphur. — In poorly nourished, low-spirited' women, who 
complain of frequent weak faint spells. 

Calcarea carb. — Poor milk, though profuse in quantity, in 
women of a lymphatic temperament. 

Sore Nipples.— In the early days of lactation, women are 
often tormented with erosions, excoriations, chaps, fissures and 
cracks of the nipple, giving rise in many cases to most intolera- 
ble suffering. The trouble generally begins with simple erosion, 
but may go on from bad to worse, only to terminate in mam- 
mary abscess. 

The affection is caused mainly by friction of the child's mouth 
in nursing, and may be obviated by suitable care of the nipples 
both before labor and during lactation. Cazeaux regards the 
exposure of the nipples to cold, while warm and moist, as one 
of the most frequent causes of the trouble. When the soreness 
is developed subsequently to the tenth day after delivery, it is 
generally due either to biting by the child, or the communica- 
tion to the nipples of an aphthous inflammation. 

When fissures have been formed, the irritation may be trans- 



The Puerperal Diseases. 691 

mitted from the base of the nipples to the cellular tissue, and 
eventually to the glandular structure itself, It constitutes a 
frequent cause of mastitis. 

Treatment should be largely of a prophylactic nature. Dur- 
ing the latter months of pregnancy, the delicate skin, covering 
the nipple, may be hardened by the frequent application of 
astringent lotions, like strong tea and tannin. Such precau- 
tions are particularly appropriate to primiparse. When lacta- 
tion begins, the nipples ought always to be sponged off with 
warm water after nursing, and gently dried, as the secretions 
of the child's mouth, if left, are capable of causing considerable 
irritation. Should erosion be set up, and refuse to yield 
promptly to the measures adopted, the child should be made to 
nurse for a time through a shield. When cracks and fissures 
exist, it may be necessary in some cases to touch the raw sur- 
faces once or twice with nitrate of silver, or strong carbolic 
acid. 

Of local applications we regard Hydrastis as among the 
best. The nipple should be washed and dried, after which the 
" fluid" Hydrastis may be applied and allowed to remain until 
another nursing. 

We have found cocaine useful in a few cases, not only to re- 
lieve the pain of nursing, but also to heal the abrasions. 

In sore nipples the woman often finds a relentless foe, and 
the physician is driven from one expedient to another in hope 
of giving relief. 

M. J. Blechmann advises the treatment of cracked or fissured 
nipples by means of goldbeaters' skin. Over the nipple affected, 
after wetting with simple clean water, there is applied a round 
piece of goldbeaters' skin, of about ten centimeters in diameter. 
The center of the skin is first pierced by a number of fine holes 
with a needle. The skin takes the form of the nipple and ad- 
heres like a second epidermis. The external surface of the gold- 
beaters' skin may now be moistened and the infant applied to 
the breast. The nipple is thus isolated from the child's mouth, 
and has a chance to heal without suffering the constant irrita- 
tion from contact with the lips of the infant. After each nurs- 
ing, a new piece of skin should be applied. 

When the crack is across the summit of the nipple we have 
sometimes succeeded by carefully filling it alone with dissolved 
gutta percha tissue. 



692 The Puerperal State. 

The following remedies, when administered on the strength of 
the indications given, will in many cases, with or without the 
use of adjuvants, be adequate to overcome the difficulty : 

Nipples itch, burn, look red: agaricus. 

Nipples sore from nursing : argentum nit. 

Nipples ulcerated : calcarea carb. 

Nipples ache, and feel sore: calcarea phos. 

Nipples nearly ulcerated off, in neglected cases : castor equ. 

Nipples bleed much, and are very sore : lycopodium. 

Nipples feel very raw and sore : mercurius. 

Nipples ulcerate easily, and are very sore and tender : caus- 
ticum. 

Nipples inflamed and very sensitive: chamomilla. 

Nipples dark, brownish red ; unbearable pain on slightest 
touch; breasts full, skin hot, pulse strong: colchicum. 

Nipples very sore to the touch ; pain from nipple to scapula 
of same side whenever the child nurses : croton tig. 

Nipples painful, inflamed, cracked : graphites. 

Nipples very sensitive, will not bear contact with the clothing: 
helonias. 

Nipples sore, fissured, or covered with scurf; bleed easily: 
lycopodium. 

Nipples itch, and have a mealy covering: petroleum. 

Nipples very sensitive : Phytolacca. 

Nipples sore and fissured, with intense suffering on putting 
the child to the breast ; pain seems to start from the nipple and 
radiate over the whole body: Phytolacca. 

Nipples sore to touch, and sore and painful spot under right 
nipple: sanguinaria can. 

Nipples are sore ; they itch and bleed : sepia. 

Nipples cracked across the crown : sepia. 

Nipples drawn in like a funnel : silicea. 

Nipples cracked; after nursing they burn and bleed: sul- 
phur. 

Nipples painful during nursing, though there is but little 
appearance of soreness: mix vom. 

Nipples in the first days of nursing feel sore as if bruised : 
arnica. 

Mastitis Puerperalis. — We have here laid tribute upon a 
report made to the American Institute of Homoeopathy, in 
1889, by the following honored members of our school : 



The Puerperal Diseases. 693 

J. B. G. Custis, M.D., Etiology and Symptomatology of 
Mastitis. 

Wm. C. Dake, M.D., Pathology of Mastitis. 

J. Nicholas Mitchell, M.D., Treatment of Mastitis. 

"Etiology and Symptomatology.— Upon first receiving 
this subject from our worthy chairman I drew a long sigh, 
thinking that I had been assigned one of such magnitude and 
intricacy that I could treat it satisfactorily only by taking the 
time to consider it under many subdivisions, divided into firstly, 
secondly, and so on to twelfthly, at least, recounting symptoms 
by the score, stopping occasionally to pay my respects to a 
few writers who have neglected the breast proper while groping 
after some fashionable cause of the fever of their patients, such 
as malaria, cold, or neglect on the part of a nurse who had not 
received proper trainiug— but lo ! upon looking into the recent 
literature of the subject, I found that I was far behind, and 
that our German friends had greatly simplified the matter, 
claiming that, in the language of one of the latest, ' every case 
of puerperal mastitis is now known to be due to infection, or, 
in other words, is caused by bacteria.' Or, as another states 
it, 'puerperal mastitis is secondary to disease of the nipples. 
These bacteria find their way into the milk either through the 
ducts or through abrasions or fissures in the nipples, infect the 
milk, and thence the train of symptoms which I will in part 
describe. If they enter through the ducts we have a paren- 
chymatous inflammation ; if through fissures, the inflammation 
is of the phlegmonous variety.' 

"You will all agree with me as to the simplicity of this 
theory, and the hints for treatment are so plain and leave so 
much play for the ingenuity of the physician, that it is with 
regret that I tell you that I cannot either prove or approve it. 
The least that we can say of it is, that it is entirely unproved, 
and until these bacteria inventors or discoverers can offer 
better results from their treatment, based on their theory, we 
will hold to the old theory, which is more rational, just as the 
treatment based on it is more rational, and more in accord- 
ance with nature that reveals such wonderful foresight and 
beneficence in the anatomy and physiology of the breast of 
woman. 

" Would the wisdom which designed that the nipple should 
have just sufficient obliquity forward and outward, with a 
slight turn upwards, so that it could be reached by the child in 



694 The Puerperal State. 

the most convenient position for itself and the mother, have 
left the duets so imperfectly protected that bacteria, even with 
all their modern improvements, could enter and poison the 
fluid which is to give life and strength to the offspring, which 
has been so conspicuously provided for ? 

" For the sake of those who are not sufficiently progressive 
to accept this modern etiology, I will consider the condition 
presented for our study under three general heads. 

I. SIMPLE SUBCUTANEOUS INFLAMMATION. 

"These cases may be accidental, so far as the puerperal 
state is concerned. Our observation leads us to believe that 
over-heating of the patient or of the breast is a common cause. 
They may or may not be associated with disease of the nipples. 
The symptoms are those of any small abscess, or of a boil. 

"There is very little, if any, constitutional disturbance. It 
may be located in any part of the gland, but is most frequently 
found near the nipple. It usually results in suppuration, with 
discharge through a single opening. 

II. PARENCHYMATOUS INFLAMMATION, OR MASTITIS PROPER. 

"In this variety the inflammation may be situated in the 
gland tissue, or in the connective tissue between the lobes of 
the gland. It may occur at any time during lactation, but is 
most likely to arise within the first ten days after labor. 

"The principal causes are: exposure to cold, mental excite- 
ment, or blows upon the breast ; but the most common is the 
retention of milk, whether because of excoriated nipples, 
inability of the child to empty the breast, or neglect on the 
part of the nurse. This retained milk causes a general conges- 
tion, which, if not relieved, will result in inflammation of the 
cellular tissue. 

"Again, we may have occlusion of some of the milk ducts, 
which will bring about the same result. Now please note the 
symptoms, and especially the order of their development. 

"First. A feeling of weight and fulness, with slight tender- 
ness of the organ, and increasing difficulty in relieving the 
breast of milk. 

"Second. Pains, shooting, darting, stitching, in any or all 
directions, especially when the child nurses. 

" Third. A slight chill, followed by fever. 

"After this we see a redness appear in spots upon the breast. 



The Puerperal Diseases. 695 

If not arrested we have suppuration, with enlargement of the 
gland, and unless the patient's constitutional condition is of 
the best, fistulse form, through which there is a discharge of pus 
and milk, the quantity varying in proportion to the extent of 
the gland involved, and the length of time taken for the abscess 
to reach the surface. I believe that in this variety this is the 
order of appearance of the symptoms in all cases. 

"Is this the order of any septic process? The first tangible 
sign of the septic process is the rigor, while in this form of 
mastitis, the most common, and that generally referred to, the 
chill does not come for some hours, often not for some days, 
after the pain and tenderness. We must still maintain the pos- 
sibility of such cases resulting entirely from engorged milk 
ducts. Treatment based on this theory is successful in allay- 
ing the inflammation and averting abscess, and it behooves us 
to combat this condition most vigorously, for, if we are not 
successful, and the inflammation proceeds to suppuration once, 
we shall have it repeated, and the fistulous openings referred 
to above will form. 

" I hope that those who follow will tell us how to cure them 
'right up.' 

III. SUB-MAMMARY INFLAMMATION, OR RETRO-MASTITIS. 

"I now ask your attention to this, the last, but most inter- 
esting division of the subject. 

"This is the form in which the most mistakes are made — 
mistakes which cause so much suffering to the patient, and 
so generally issue in the destruction of the function of the 
organ. 

" To understand this condition we must glance at the general 
anatomy of the breast. 

"The gland is supported by two layers of fascia, between 
which it yields to pressure. While the fascia thus supports, it 
also firmly unites its several fractures. 

"In many cases the fascia forms a synovial bursa at the 
base of the gland, which bursa separates it from the great pec- 
toral muscle, the sterno-costal cartilages, and the ribs. The 
tissue has the appearance of foliated laminae instead of being 
smooth. 

"We recognize here the possibility of an inflammatory con- 
dition in any or all of its varied forms. The inflammationis the 
result of the development of the gland under some abnormal 



696 The Puerperal State. 

or unfavorable condition, which may be some more or less pro- 
nounced variation from the normal formation of the gland, or 
it may be cold from undue exposure of the breast. 

"My observation leads me to think that inflammation in 
most of these cases cannot be averted, though it can be con- 
trolled. 

" The symptoms of this form are very characteristic. Three 
or four days after confinement the patient is seized with severe 
rigors and sense of chilliness, with great thirst, dry mouth, and 
rapid pulse, not unfrequen tly reaching 140 a minute. The head 
aches fearfully, as do the limbs also, and pains may be present 
in the abdomen, due to the rigor. This is followed by a severe 
hot stage that lasts from two to fourteen hours, and this by a 
sweating stage that brings speedy and gratifying relief. The 
patient makes no complaint of the breast, 

"At about the same hour the next day the symptoms are 
repeated, and again on the third day, unless the physician is 
successful in his efforts to subdue the inflammation. If he is 
not, the patient, after the second or third chill, begins to com- 
plain of the breast, and soon we have the unmistakable signs 
of mastitis, such as I have described above, which may end in 
suppuration, in which case the process will be tedious and the 
time long before the pus reaches the surface. 

"If the physician is successful in allaying this first attack of 
inflammation, and is not especially watchful, the same symp- 
toms will recur after a few days. 

"As my time is limited I will not repeat the symptomatology , 
but only call attention to the fact that many authors consider 
sub-mammary inflammation to be secondary to disease of the 
chest, or to a parenchymatous inflammation of the gland. I 
think this is a mistake; that indeed these are never the primary 
causes, but on the other hand, when sub-mammary inflamma- 
tion is neglected or badly treated, it may cause disease of the 
chest. 

"It has been my misfortune to see many cases of this con- 
dition, and they have all followed exactly the course of develop- 
ment given above, and you will please note the general 
similarity of the symptoms to those of malarial or intermittent 
fever, namely, chill, fever, sweat; with recurrence of chill on the 
following day at about the same hour. 

"I have known this condition to be mistaken for intermittent 
fever ; and because the physician did not examine the breast. 



The Puerperal Diseases. 697 

"The patient will not complain of it; in fact, may not 
complain until after the second or third chill, with its succeeding 
fever and sweat, though she will say the breasts are tender, 
'the result of the fever,' but the seat of inflammation is under 
the gland, which must be pushed aside and examination be 
made as far under it as possible, and then we shall discover the 
seat of the trouble. 

"Gentlemen, this is personal experience, and I would 
emphasize it. 

"Not long ago I had a physician send me a message from 
Michigan, telling me how his patient, whom I was treating for 
retro-mastitis, contracted malarial fever, of which she did not 
show a sign. 

"In the iY. A. Journal of Homeopathy for December, 1887, 
you will find a paper on the ' Malarial Complications of the 
Puerperal State,' in which the author gives the same symptoms 
that I have given above for the beginning of retro-mastitis, and 
tells us how frequently the symptoms of malaria show them- 
selves in connection with the puerperal state, and how it is 
necessary, if treated successfully, to treat it with quinine. His 
cases under this homeopathic (?) treatment follow just the same 
course as retro-mastitis does without it; and here again we see 
the ease with which the two can be confounded. The course is 
that of malarial symptoms suppressed by quinine, and return- 
ing at stated periods. 

"I do not deny the possibility of malarial poison attacking 
a woman in the puerperal state, and have called attention to it 
in another place; though I do doubt the frequency of cases 
which manifest themselves for the first time during the lying-in 
period. My experience is that all such cases show a malarial 
history previous to confinement, and my rule is never to make 
a diagnosis of '' malarial ' until I have carefully eliminated the 
possibility of retro-mastitis and of septicaemia. 

"I will say, in closing, that, if our bacteriologists can find 
any place for their favorites in mastitis, they must choose this 
latter form, and must find some other place of entrance for 
them than through the nipple or possible fissures. 

"Other forms of disease of the breast do not belong to us, 
for the reason that if they occur during the puerperal state 
they are either secondary, metastatic or accidental as far as the 
period under consideration is concerned. " 



698 The Puerperal State. 

Pathology.— "According to pathologists there are three 
varieties of inflammation of the mammary gland : 

" 1st. The subcutaneous ; 

"2d. The glandular, and 

"3d. The sub-glandular. 

" 1. Of these, the first, or subcutaneous, when not extending 
into or causing the second, is by far the simplest, the least 
severe, and the least likely to cause serious trouble. It is usu- 
ally a simple inflammation of the areolar tissues lying above 
the gland, and runs, when uncomplicated, much the same 
course as an inflammation in any similar structures, ending 
either in resolution or suppuration. When ending in resolution, 
which is rare, we find the redness, pain and swelling diminish ; 
the localized induration lessen; the constitutional symptoms, if 
there were any, disappear ; nursing becomes less painful ; and 
shortly all traces of the affection vanish, leaving the breast as 
before the attack. 

"If, on the other hand, the inflammation does not subside 
we find the engorgement of the tissues increasing ; the tender- 
ness growing greater; the inflamed area extending; nursing 
becoming more and more painful, or altogether impossible ; the 
lancinating pains unendurable, and finally rigors or a positive 
chill ushers in the formation of pus. 

"Usually in the subcutaneous or superficial variety we find 
the abscess single, pointing near the nipple, running its course 
rapidly and ending by incision, or spontaneously discharging 
through the skin, or into the ducts and through the nipple, 
leaving the gland itself in an uninjured condition. Frequently, 
however, it does not run this straightforward course, but the 
pus, making its way in the direction of least resistance, extend- 
ing and deepening, it opens into the gland, setting up true 
glandular mastitis ; or by its involvement of the nipple, the 
tumefaction and interference with the free discharge of the lac- 
teal secretion, it causes a general engorgement of the gland, 
and thus sets up a secondary inflammation, which speedily be- 
comes active, leading to the formation of the true glandular 
mammary abscess and its consequent troubles. 

"2. In the glandular variety of mammary inflammation, 
when occurring primarily, we find usually some circumscribed 
spot which is sensitive to pressure speedily followed by a sense 
of heaviness and weight in the entire breast, with lancinating 



The Puerperal Diseases. 699 

pains and an engorgement of the vessels of the gland. Soon 
swelling begins, a flush appears, the temperature rises, and the 
inflammation is fully established. By the tumefaction the 
calibre of the ducts is lessened and the flow of milk diminished, 
and its retention aids in increasing the pain and spreading the 
inflammation. 

''Inflammation of the gland ends either in resolution, which, 
alas! is too infrequent, or in suppuration. When resolution takes 
place we find changes most pleasant to see. The redness, pain 
and swelling grow less, the induration gradually disappears, the 
flow of milk increases, and soon there exists only the remem- 
brance of trouble and a fear of it, which lasteth long. 

"When it proceeds to suppuration, the engorgement, the 
redness and sensitiveness, the pains and the interference with 
the flow of milk, the induration and the constitutional symp- 
toms all increase. An intense restlessness tortures the patient, 
and soon a hard chill, or more than one, indicates the forma- 
tion of pus. The swelling increases, the skin becomes hot, red 
and (edematous, fluctuation becomes apparent, increasing as 
the quantity of pus increases, and draws nearer the surface. 
Soon, in the milder cases, the abscess points, and by incision, or 
by spontaneous evacuation, discharges its contents. Often the 
pus is discharged, mixed with the milk, through the ducts, and 
without external opening. 

" In the more severe cases there may be more than one point 
of discharge, leaving fistulous openings through which pus and 
milk escape for some time, exhausting the patient and doing 
infinite damage to the breast and its future usefulness. At 
times, even when the abscess is small and the symptoms mild, 
the discharge occurring early, and the subsequent healing being 
rapid, we find, shorty after the case is apparently at an end, 
another abscess forming, which runs a course similar to the 
first, ending in discharge; and shortly, again, another, forming 
an exhaustive succession, producing collectively a most serious 
effect on the patient's general health, and leaving the gland 
often permanently indurated and useless. 

"Occasionally the inflammation of the gland becomes 
chronic, lasting for weeks or months before suppuration takes 
place, and going through its various stages with extreme slow- 
ness, but with all the accompaniments of pain, swelling and 
engorgement belonging to the more acute forms. 

" Though the usual result of abscess of the mammary gland 



700 The Puerperal State. 

is to impair its secreting power, it sometimes happens that the 
gland resumes its full function after a severe abscess. When 
this occurs, however, the tendency to a return of the trouble is 
increased. 

"3. In the third or sub-glandular variety we find the pri- 
mary inflammation seated in the deep cellular tissues underly- 
ing the gland. Owing to the dense mammary gland above, and 
the unyielding chest wall below, the pain from the beginning is 
more severe than in the other forms of mastitis. There is at 
first little but the pain to indicate trouble ; if, however, the in- 
flammation does not subside, but continues, there soon appears 
an elevation of the entire gland, the pain increases, becoming 
more and more severe, a diffused flush appears, and soon a chill 
shows the formation of pus. The constitutional symptoms be- 
come more distressing, the breast is elevated and seems to float 
upon a sea of pus. The pus forms slowly, and with extreme 
slowness makes its way to the surface, frequently finding exit 
through several openings, leaving long fistulous tracts, which 
heal slowly and exhaust the strength of the sufferer. 

"Sometimes the pus escapes upwards, passing into and 
through the gland. In this variety there is but little interfer- 
ence with the secretion, until the extreme sensitiveness prevents 
nursing and leads to lacteal engorgement, or the drying up of 
the milk. 

"The injury to the gland itself is often trifling compared 
with that left by the glandular form; and even after a long- 
continued suppuration, fistulous troubles and great exhaustion, 
we may find another and luckier child thriving on the product 
of the self -same breast." 

Treatment.— "As soon as inflammation of the breast is 
certainly made out, the first duty of the attending physician 
will be to discover the cause, if possible, and to remove it. 
Careful examination of the nipple should therefore be made for 
any cracks, fissures, or abrasions, since these are so often the 
causes of the deeper-seated inflammation, and such lesions 
should receive the treatment appropriate to whichever may 
exist. A careful and thorough examination should be made of 
the extent of the inflammatory process, since different treat- 
ment will be indicated according as to whether the inflammation 
is deep seated in the parenchyma of the breast, or more super- 
ficially in the superficial connective tissue. 

"In the latter case there is usually but little suffering, com- 



The Puerperal Diseases. 701 

paratively, seldom enough to prevent the mother from nursing 
her child, and therefore the notice of the physician is not often 
called to the trouble until it has advanced to the stage of sup- 
puration, or is so far advanced that suppuration is inevitable. 
Under these circumstances the treatment called for is simply 
the application of such means, like poultices, as will encourage 
rapidly the formation of pus, which should be evacuated as 
soon as discovered, by incision into the abscess made in the line 
of the milk ducts and running towards the nipple. 

" This usually ends the trouble, unless there have been several 
points of inflammation. If there is not much pain from nurs- 
ing, or in the opening of the abscess no communication has been 
made with the nipple by the cutting open of a milk duct so as 
to permit the mixture of pus with the milk, the woman should 
be encouraged to continue nursing her babe, while all proper 
care is given to any trouble that may exist in the nipple. 

"Should the inflammation, however, be found to extend 
down deep into the parenchyma of the breast, that form which 
is more frequently found to exist at the puerperal period, the 
indications for treatment, other than those already pointed out 
in the removal of the cause, are to bring about rest and freedom 
from pain, the object of the treatment being, if possible, to 
bring about resolution, and thus leave the organ in a condition 
to continue its function. 

"The rest must be absolute. Rest from functional activity, 
rest from handling, rest from the dragging of its own weight, 
and, at the same time, rest from pain, with its accompanying 
feverishness and restlessness. 

" To bring about this rest, the physician must first order the 
woman to stop nursing from the inflamed breast entirely, and 
furthermore forbid all rubbings, frictions, or use of the breast- 
pumps to remove the milk under the mistaken notion that the 
retained milk is the cause of the inflammation, and he should 
watch carefully that his orders in both respects are obeyed. 

"In the early stage of the inflammation, and while resolution 
is possible, I think all medicinal applications are useless, though 
I have, at times, in accordance with the advice of some, made 
use of Deshler's salve, Iodide of lead ointment, and Belladonna 
ointment. I am fully convinced, however, that useful as such 
applications may be in the condition of engorgement preceding 
inflammation, they are of no use when the latter has occurred. 

"Particular warning is to be given against the nse of hot 



702 The Pueeperal State. 

poultices for so long a time as resolution is possible, as they 
only favor suppuration, and their prolonged use has the effect 
to soften and make boggy all the structures." 

[We set great store by the thorough use of hot fomenta- 
tions, and have seen no suppuration where they were faithfully 
used from an early moment.] 

"The method of treatment that I have found most satis- 
factory has been that of bandaging. The breast is first covered 
with cotton wool, and a bandage well and carefully applied, 
with sufficient pressure to uphold the breast, by its support, 
from the dragging weight so much complained of by women, 
and, at the same time, by its compression it keeps the breast 
perfectly quiet, and is further useful, if applied by the physician 
himself, as a guard against meddlesome interference by the nurse 
or by some well-meaning but mistaken relative. This bandage 
should be carefully applied new each day, and will, with the 
appropriate homeopathic remedy, frequently produce a resolu- 
tion in three or four days, when nursing can be carefully renewed 
and continued. Should the inflammation continue, and instead 
of resolution suppuration occur, a condition of things which 
may be suspected if the fever and pains continue a number of 
days notwithstanding the rest, bandaging, and exhibition of 
the indicated remedy, and may be diagnosed with certainty if 
the fever, which has declined, suddenly increases, and with it 
there is an increase of pain with chills or chilly sensations ; while 
the swelling becomes softer and more boggy-feeling to the touch 
and more superficial in appearance, the use of the bandage 
may be done aw r a t y with and warm flaxseed poultices applied, 
changing them often enough to keep up a constant application 
of moist heat. 

"As soon as pus can be discovered and located, the abscess 
must be opened and free exit given to the pus. 

"If it be superficial, it is easily opened by a linear incision 
running in the line of the milk ducts towards the nipple. If the 
situation is deep it may be necessary to etherize the patient. 
An incision is then made through the skin and superficial fascia 
overlying the most prominent part of the swelling ; a grooved 
director should then be forced through the tissues into the ab- 
scess, and along the groove of the director a pair of ordinary 
dressing forceps be guided into the abscess, when, by opening 
the handles, the tissues will be pushed far enough apart to give 
exit to the pus. 



The Puerperal Diseases. 703 

" If there are several abscesses, each must be opened in this 
way, and if there are dependent pockets from which pus cannot 
flow by its gravity, counter-openings must be made at the 
most dependent positions until there is secured a free drainage, 
as otherwise, notwithstanding the openings, the pus will de- 
compose and burrow, causing fistulous attacks and constitu- 
tional symptoms. 

"In these deep-seated abscesses drainage-tubes must be 
used, and the track of the abscess washed out daily with boiled 
water until such time as the water flows back clear, when they 
may be removed and the breast carefully bandaged and com- 
pressed. 

" The most satisfactory manner for producing this compres- 
sion is the use of a compressed sponge, as suggested by Gross. 
His method is to take a clean, flat, compressed sponge and en- 
velop the breast, already covered with cotton-wool, with it. A 
neatly-fitting bandage is then applied and water introduced 
through the bandage onto the sponge, which swelling causes 
an even compression of the breast, relieving the engorge- 
ment and, at the same time, pressing together the abscess 
walls. 

"In certain rare cases the inflammation and suppuration 
occur in the connective tissue between the thorax and the 
breast. When this is diagnosed by the deep-seated character 
of the pain and swelling, and by the manner in which the breast 
is lifted up and pushed away from the thorax, the abscess must 
be opened as soon as pus is suspected without waiting for any 
pointing, as from its locality there is great danger of extensive 
damage resulting from the burrowing. The breast is lifted 
away from the thorax, and the opening made from below at the 
most dependent position. 

"I have said nothing about the use of remedies to be given 
internally beyond the directions to give that which is best indi- 
cated, because I have no new remedy or remedies to propose, 
and cannot feel justified, in an article like this, in taking up 
space with a copy of matter already well written up in our 
repertories and text-books. 

"It is undoubtedly a mistake, in my opinion, to pin one's 
confidence alone on the homeopathic remedy in cases of this 
kind to the neglect of procuring rest to the part by bandages, 
rest being always indicated to all inflamed parts ; and I think, 
on the other hand, that it may safely be considered as equally 



704 



The Puerperal State. 



unwise to depend only upon the mechanical treatment to the 
exclusion of the homeopathic remedy ; but with the two in com- 
bination, and with the exclusion of all useless local applications, 
I have found but a small number of cases where I have failed 
to bring about resolution. But it must not be forgotten, that 
when it does fail, and suppuration does occur, it takes the case 
out of the domain of medicine into that of surgery, and that to 
prevent the mischief that confined and burrowing pus will 
cause in tissues so easily burrowed through and destroyed, the 
knife must be used, and used early." 

Therapeutics.— The following repertory of mastitis is from 
that worthy son of a noble father, William J. Guernsey, 
M.D., and was published in a recent number of the Medical 
Advance. 

u As Lac caninum and Phytolacca are far ahead of any other 
remedies in aborting this trouble, a comparison may be of 
service. 



PHYTOLACCA. 



Affects one breast as much as the 
other ; as Phytolacca acts particular- 
ly on the right and Lac can. on either, 
it may be given preference to the left. 
If there has been soreness or pain 
alternating from one breast to the 
other, or migratory trouble of any 
sort about the patient, it should be 
used. 

Much soreness, fullness and pain, 
but not so much inflammation, al- 
though this latter should not rule it 
out of consideration. 
Very much worse from least jar ; 
has to support the breast in walking 
about, especially on going up or 
down stairs. Even worse from in- 
spiration. 

Induration in small lumps like mar- 
bles. Considering the fact that its 
membranous exudation in the throat 
is in small specks, I have (on the 
rule of similars) marked this " nodu- 
lated breast" high under Lac can. 
Markedly worse towards evening — 
and EVENING. 



Right breast. 



Inflammation marked with soreness, 
fullness, and pain. 



Not so pronounced. 



Same in lesser degree ; but it has 
cured for me many cases of a single 
stony induration. 



Worse after midnight; better in 
afternoon. 



The Puerperal Diseases. 



705 



REMEDIES IN GENERAL AFFECTING THE 



Mammae. — Aeon., aes., aeth., agar., 
agn., all. s., alum., amb., am. c, 
am. m., anac, ang., ant. c, ant. t., 
apis, arg. n., arn., ars., arum, 
asai, bary. c, bell., berb., borax, 
bov., brom., bry., cac., cal., cal. p. 
calad., camph.. can. s., canth., 
carbo a., carbo v., castor, caust., 
cham., chel., cinch., cic, cim., 
cina., cist., clem., coc, coff., col., 
con., crot. t., curare, eye, dig., 
dul., frag., gamb., gels., graph., 
grat., guaiac, ham., hep., ign., 
ipec., iod., kali b., kali e, kreos., 
lac can., lac def., lach., lact., 
laur., led., lepi., lil. t., lye, mag. 
e, mang., mer. c, mer. s., mer. v., 
mez., mill., mosch., mur., nat. e, 
nat. m., nic, nit. ae, nux j., nux 



Mammae — Continued. 

v., op., pet., phel., phos., phos. ac, 
phyt., plat., plumb., prun., psor., 
puis., ran. b., ran. s., raph., ratan., 
rheum., rhod., rhus., ruta, sabad., 
sab., samb., sang., sars., sec, sep., 
sil., spong., squil., stan., staph., 
stram., sulph., tar.,ther., uva u., 
verat., zinc. 

Mammae Left, aeth., agar., alum., 
amb., apis, berb., bor., bov., cac, 
cal., cal. p., cis., con., eye, grat., 
lac can., lil. t., lye, mag. c, 
mosch., phel., phos., phyt., 
plumb., sil., spong., zinc. 

Mammae Right, all. s., amb., cal., con., 
gamb., grat., kali b., kreos., lac 
can., mez., phyt., plumb., psor., 
sang., sil., zinc. 



SUBJECTIVE SYMPTOMS. 



Aching, apis, bov., con., lac can., lil. t., 

mosch., stram., zinc. 
Air, streaming through, eye 
Burning, aes., amb., apis, ars., bell., 

cal. p., con., iod., laur., led., lye, 

phos., sang. 
Coldness, cim., coe, dig., rhus. 
Compression, ther. 
— backward, ther. 
Constriction, lil. t., sang. 
Contraction, bor., cal. p., stram., verat. 
Cord, around. 

Cramp-like pain, lil. t., plat. 
Cutting, bell., lepi., lach., lil. t. 
Darting, carbo a., grat., iod., kali b. 
Drawing, cal. p., kreos., lil. t. 
Fulness, bell., bry., clem., eye, lac 

can., lact., mer. v., nux v., phyt., 

see, sep. 
Grasping, lil. t. 
Griping, bov. 
Gurgling, crot. t. 
Heaviness, bell., bry., clem., lil. t, 

ther. 
Itching, agar., alum., anac, ant. e, 

arn., ars., bary. e, berb., bov., 
(45) 



Itching— Continued. 

cal., canth., carbo v., caust., con., 
kali e, led., lye, mez., nat. m., 
nic, nux j., phel., phos., plumb., 
rhus., sabad., sep., spong., squil., 
stan., staph., sulph. 

Lancination. See Cutting. 

Milk flowing in, as from, kreos. 

Pain (undefined), ang., ant. e, arn., 
bary. e, bell., bor., bry., cac, 
calad., cal., con., crot. t., eye, 
iod., kali b., lach., lac can., laur., 
lil. t., mer. s., murex., phel., phos., 
rheum., rhus, sang., sil., verat., 
zinc. 

— extending backwards (through chest; 

to lumbar region; to scapula; to 

spine), lil. t. 

downward to navel, agar. 

side, prun. 

-forwards beneath sternum, sang. 

inwards, phel. 

— - — nipple (from periphery to the), 

kreos. 

outward, gels., mez. 

upward to arms, curare. 



706 



The Puerperal State. 



subjective symptoms — Continued. 



Pain, extending upwards to neck, HI. t. 
shoulders, lil. t., mag. c. 

— labor, as though from, lach. 
Pinching, agar., cal. p. 

Pressure, am. m.,cal. p., phos., phos. ac. 

— acute, phos. ac. 
Prickling, cal., cim., ran. s. 
Pulsation, bell. 
Rawness, mer. v. 
Sensitiveness. See Tenderness. 
Shivering, as if, guaiac, nux v., 

pet. 

Shooting, cal. p. 

Soreness, all. s., ang., arm, arum, bry., 
calad., cal., cal. p., cic, graph., 
lac can., mer. c, nat. m., phyt., 
rhod., sang., sep., sil. 

Stitches, aeth., all. s., alum., amb., 
apis, arg. n., bary. e, berb., bor., 
bry., cal., carbo a., cim., clem., 
con., eye, gamb., gels., graph., 



Stitches — Continued. 

grat., ign., jod., kali b., kali c, 
kreos., laur., lil. t., lye, mag. c, 
mez., murex, nat. m., phel., 
phos., plumb., prun., psor., 
rheum, sang., sep., sil., thuja, 
zinc. 

— fine, plumb. 

Suppurative pain, cal., clem., hep., 
phos., plumb., sil. 

— sensation, sil. 
Swelling as if, berb. 

Tearing, amm. e, amm. m., bar. c, 

cal., cal. p., carbo v., con., crot. 

t., grat., kali e, sang. 
Tenderness, cal., cham., clem., con., 

graph., lac can., mer. v., nat. m., 

phyt., ther., zinc. 
Tension, eye, puis. 
Tingling, sab. 
Unpleasant (indescribable), phos. 



OBJECTIVE SYMPTOMS. 



Abscess. See Suppuration. 
Atrophy, ars., con., frag., iod., kali i., 

kreos., nit. ac, nux m., sars. 
Bluish, livid hue, lach., phos., plumb. 

— red hue, kreos. 
Distension, eye, zinc. 
Emaciation. See Atrophy. 

Fever (milk fever), aeon., arm, bell., 
bry., cham., coff., ign., mer. v., 
op., rhus. 

Flabbiness, bell., camph., con., iod. 

Heat in, aeon., bell., bry., cal. p., 
mang., raph., sulph. 

Induration, arm, bell., bry., cal., cal. 
p., carbo a., cham., clem., col., 
con., eye, graph., ham., lac can., 
lepi., lye, mer. v., nit. ac, phos., 
phyt., plumb., puis., ruta, sep., 
sil., spong., sulph. 

Inflammation, bell., bry., cal., carbo 
a., carbo v., cist., con., hep., lac 
can., mer. v., phos., phyt., sil., 
sulph. 

Milk, bad tasting, bor., mer. v. 

— bitter tasting, rheum. 



Milk, bluish, lach. 

— cheesy, cham. 

— copious (too), aeon., ant. t., asaf., 

bell., bor., bry., cal., cinch., con., 
iod., kreos., lach., lac can., lye, 
nux v., phos., phyt., puis., rhus, 
stan., staph., stram. 

— purulent, cham. 

— retarded by cicatrices, graph., phyt. 

— salt tasting, carbo a. 

— scant, agn., asaf., bell., bry., cal., 

caust., cham., chel., cinch., dul., 
lac can., lye, mer. v., mill., phel., 
phos. 

— spoiled, bell., bor., carbo a., cham., 

cina., ipee, lach., mer., nux v., 
puis., rheum, samb., stan. 

— stringy, kali b. 

— thick, bor. 

— thin, carbo a., kali b., lach., puis. 

— wanting, agn., asaf., lac can., urt. u. 

— yellow, rheum. 

Redness, radiating from center, bell., 

sulph. 
Redness, streaks of, phos., rhus. 



The Puerperal Diseases. 



707 



objective symptoms — Continued. 



Suppuration, inevitable, hep., sil. 

— threatened, asaf., bell., cal., cist., 
dul., kali e, kreos., lac can., 
mer. v., nat. e, phos., phyt., 
puis., sep., sulph. 

Swelling, aeth., all. s., apis, asaf., bell., 
berb., brom., bry., cal., cham., 
clem., con., eye, dul., graph., 



Swelling— Continued— 

hep., lach., lac can., lye, mer. c, 
mer. s., mer. v., phos., phyt., 
plumb., puis., rat., sab., samb., 
sil., sulph., tar., uva u. zinc. 

— lumps like marbles, lac can., phyt. 

Uncertain, phos., phyt., sil., sulph. 

— fistulous, phos., phyt., san., sil. 



AGGRAVATIONS AND AMELIORATIONS. 



Afternoon, < aeth., bell., bry., nit. ae, 

phos., puis., sang. 
Ascending stairs, < bell., cal., carbo 

a., lac can., lye, nit. ae, phos. 
Bed (in), < mur. 
Bending forwards, < grat. 
Breathing in. See Inspiring. 
Cold, < from, sep. 

— taking < aeon., bell., bry., cae, 

cal., cham., dul., mer., nux, 

phos., puis., rhus. 
Contusion, < arm, carbo a., con., 

ham. 
Day < con. 
Empty, < when, bov. 
Erect < on becoming, graph. 
Evening < arm, bell., bry., con., lac 

can., nit. ae, phos., puis., spong. 
Exercising, < ang., laur., ran. b. 

— arms, < ang., ant. e 

— open air, •< am. m. 
Flow of milk, > eye 

Holding them. See Supporting. 
Inspiring, < carbo a., grat., lac can., 

mag. e, plumb., prun. 
Inspiring deeply, < prun., sang. 
Jar, < bell., cal., carbo a., lac can., 

lye. nit. ae, phos. 
Lifting. See Supporting. 
Lying, on left side, < HI. t. 

— painful side, < lil. t. 
Menses < after, eye, ther. 

— before, cal., con., eye, lac can., 

sang., spong. 

— delayed, bar. e, cal., con., dul., 

iod., mer. v., phos., rhus, ther., 
zinc. 



Menses, during, cal., carbo a., caust., 
con., dul., iod., lac can., lac del, 
mer. v., phos., sang., ther., zinc. 

— suppressed, rat. 

Morning, < calad., cal., carbo v., chel.» 
lit. t., nux v., rhus, sang., zinc. 

— > spong. 

— bed, < in, plumb. 
Motion, < sep. 

Night, < aeon., arn.,ars., cham., con., 
dul., graph., hep., iod., mer., nit* 
ae, plumb., sil. 

Noon, < mag. e 

Nursing, < bor., carbo an., crot., kali 
e, phel. 

— opposite breast, < bor. 
Paroxysmally, < castor. 
Periodically, < ars., kreos., mer. s. 
Position, change of, > lil. t. 
Pressure, < ant. e, cal., carbo a., lac 

can., mer. v., murex. 

— murex. 

— >, kreos. 
Rest, <, rhus. 

— >, kreos. 
Riding, <, sep. 
Rubbing, <, con. 

— >, castor. 
Sitting, <. prun., ther. 
Sneezing, <, phos. (Compare Jar.) 
Stretching body, <, ther. 
Supporting breast, >, bell., cae, cal., 

carbo a., lac can., lye, nit. ae, 

phos. 
Touch, >, cal. 
Walking, <, lac can., prun., sep., 

stram. 



708 The Puerperal State. 



CHAPTER IV. 

PUERPERAL FEVER {CHILD-BED FEVER). 

Definition. — A form of fever peculiar to the puerperal state, 
from autogenetic, as well as from hetero-genetic causes ; usually 
occurring from the third to the fifth day after labor, with an 
average duration of seven to fourteen days ; terminating in 
convalescence and recovery, or death. In exceptional cases a 
series of sequelae may happen, spreading over a period of weeks 
or months, consisting of abscesses, pyaemia, hydropsic condi- 
tions, decubitus, debility and death. 

Dr. R. Barnes, of London, says: "As fevers of various kinds 
may assail non-puerperal persons, so they may assail puer- 
peral. We must therefore consider puerperal fever as a fever in 
<a puerpera, and abandon the vain attempt to find only one 
definite puerperal fever, but recognize the clinical fact that 
there are puerperal fevers." 

History. — It has probably been the occasional affliction of 
the parturient woman in all the ages and experience of human- 
ity. There is traditional authority for supposing that Rachel, 
the beloved wife of the patriarch Jacob, died of this disease, it 
being the first case of puerperal fever of which we have any 
record. It may be either epidemic, traumatic or sporadic. It 
is always most violent in the epidemic form. The earliest of 
medical literature gives accounts of the disease, and we have 
excellent examples in the writings of Hippocrates, and the 
Arabian physician Avicenna. It prevailed in Paris as an 
epidemic in 1746, with, great mortality. In 1786 it raged 
epidemically with great violence in the flat malarial plains of 
Lombardy, from which -'not a single puerpera recovered." In 
1740 London had an epidemic, when "every female seized 
with the malady succumbed." As late as 1860 and 1863 it was 
epidemic in various parts of Germany, especially in the lying-in 
institutions, and very fatal. Its great prevalence and mortality 
in the experience of certain practitioners has at times been 
noteworthy ; so as to drive them for a time from practice. 

So great an authority as the late Professor Charles D.Meigs, 
regarded puerperal fever as either a metritis or a peritonitis, 
and insisted that it was not contagious ; but says : " What the 
real essence of this epidemic is, I believe no man can say." In 



Puerperal Fever. 709 

Philadelphia many years since, there was a certain Dr. Kutter 
cotemporary with Dr. Meigs, a noted physician, who had a 
large practice confined to midwifery, and his clientage was 
among the first families of Philadelphia. During one year he 
had seventy cases of puerperal fever. On account of his bad 
experience, he was charged with being " a carrier of contagion," 
and so he gave up practice and left town for some weeks. On 
his return, he changed his clothing, took a bath, shaved his 
head closely, and left behind his watch, pencil and other per- 
sonalities that he had about him previously. He then went 
out and attended a lady in labor; the parturition was not 
difficult, but the patient was soon attacked with child-bed fever, 
from which she succumbed. It was, upon a careful investiga- 
tion, proved that all the cases of the disease that had occurred 
in his practice came from external infection (a hetero-genetic 
cause). The contagion was transmitted manually from Dr. 
Rutter himself, for he had been affected with a bad ozena, prob- 
ably syphilitic, and the poison from this disgusting malady, 
with its bad odors, was through him carried directly to his 
patients; so that he infected nearly every puerperal woman 
that he came in contact with. The route of contagion was 
from the nose to his pocket-handkerchief, thence to his hands 
and fingers, and then easily to his patients. This remarkable 
case of contagion, propagated by a distinguished physician and 
specialist, reminds us of the words of Dr. Emmet: "Many a 
woman's death-w arrant is carried under the nails of her 
surgeon." 

With puerperal disease we may have insanity. Probably 
moral, as well as hereditary, causes have an influence in its 
development, especially among the upper classes. Again, a 
puerperium with any hereditary taint of insanity will be more 
liable to mental troubles that may be developed during preg- 
nancy or confinement, in the form of either mania, melancholia 
or monomania, usually the first named. 

Among the laboring-classes, plrysical causes, exposure, hard 
life, poor nourishment, and anaemia may be reckoned as factors. 
Lastly, young women with concealed pregnancies, or abortions 
with illegitimate offspring, may have mental ailments, even 
mania, during their lying-in period. 

Etiology. — Woman in her puerperal state seems to lose for 
the time much of what the old authors called the vis conserva- 
trix naturae; that is to say, she loses the pow T er to resist the 



710 The Puerperal State. 

adverse influence of any toxic or traumatic agency by which she 
may happen to be environed. There is now no longer any rea- 
son to doubt that if she be surrounded by cases of typhus, 
diphtheria, scarlet fever, erysipelas, or have a violent labor with 
injuries to the soft parts, her danger of puerperal fever will be 
greatly increased. It must be admitted, however, that some 
occult influence may produce an occasional case, where none of 
the above named agencies seem to have any part. The close, 
bad air of large hospitals, and their nosocomial emanations, 
may serve as a cause. 

It may be caused by the absorption of decomposed matters 
within the uterine cavity, as in the case of abortion, when the 
delivery is incomplete and the after-birth only partially 
delivered. The remains of the placenta and coagula left behind 
may cause irritation and inflammation tha/fc may induce septic 
fever. It may be contracted by contagion from another puer- 
peral patient suffering from the same infection, especially during 
the prevalence of an epidemic. After a severe and lingering 
labor, if the perineum is badly lacerated, and the injury left un- 
repaired, puerperal fever is more liable to attack the patient 
who has not been operated upon* 

Medical men who attend patients in hospitals, who make 
post-mortems, visit dissecting rooms, are not always scrupu- 
lously clean in their persons, do not bathe themselves and care- 
fully change their clothing, and wash their hands in antiseptic 
solutions immediately before coming into the lying-in room, 
may infect a puerperal patient with the fever. 

Nurses who are untidy and careless in their persons, and do 
not care for the patient properly, may themselves be responsi- 
ble for the disease. Any neglect to keep the patient's person 
clean, especially in hot weather, may serve as direct or predis- 
posing cause. 

An acute gonorrhoea at time of labor may, by inducing 

* Before leaving a lying-in patient, the accoucheur should satisfy himself by ocu- 
lar evidence whether any rupture of the perineum has occurred. If a rent is found, 
and it extends over one-half or three-fourths of an inch, it should be repaired immediately. 
Every accoucheur should be prepared for such an emergency. A good pocket case of 
instruments containing straight and curved needles, a forceps needle-holder and Chinese 
silk, or silkworm gut ligatures will be required, and with the aid of the nurse the lacera- 
tion should be repaired within the first six or twelve hours after delivery. If the immedi- 
ate operation is not made, the patient is necessitated to wait for three months for the 
secondary or remote operation, and will have to go through with the anxieties, trials, 
expense and dangers of a "second lying-in." The immediate operation is much easier for 
the patient than the secondary. Usually within four or five days union takes place. 

T. G. C. 



Puerperal Fever. 711 

salpingitis, result in the fever. It should be known to the 
profession that gonorrhoea involving the fallopian tubes sub- 
jects any woman who conceives to many dangers. Experience 
proves that abortion or labor aggravates an existing gonor- 
rhoea, be it acute or chronic, and after such a labor, a "gonor- 
rhoeal puerperal fever,'' or a gonorrhceal peritonitis, may 
follow, from which the woman is liable to succumb. 

Frequency.— This fever is rare except as an epidemic in large 
cities and hospitals, so that a country practitioner who may 
not have had experience with an epidemic, may go through a 
large and long professional experience and not see more than 
half a dozen cases. 

Symptoms.— The first symptom is usually a chill or rigor, of 
short duration, followed by a violent reaction ; as indicated by 
great heat of the bodily surface, high thermometric range in 
all the cavities that can be approached— 102° to 104° ; pulse 110 
to 120 ; hasty short respiration with all the manifestations of 
great bodily distress and unrest. The pulse is small, quick, 
thready. The tongue is coated, dry, brown, with an unquench- 
able thirst. More or less of delirium usuallvcuts a figure in these 
cases. The bowels may be either confined or diarrhoeic. The 
urine is scanty and highly colored, with strong disagreeable 
odor. The lochia is suppressed altogether, or if present, in 
small quantity, is dark, thick and foetid. There is loathing of 
food, and sometimes nausea and vomiting. Simultaneously, 
or almost immediately after the appearance of the febrile symp- 
toms, we discover evidences of certain important local phlegma- 
sia?, in the shape of metritis and peritonitis. The entire abdomi- 
nal and pelvic contours become greatly distended, very painful, 
excessively tender and very hot. There is usually much pain in 
the head and a severe backache. There has been much disquisi- 
tion and controversy as to whether there may be a genuine 
fever without these local manifestations and complications. To 
affirm or deny this view of the matter might be scientificalh 7 
unsafe and rash, at least as to exceptional cases. But we think it 
safe to affirm that the almost simultaneous appearance of the 
fever with these local indications is such as to render the fever 
and the local phlegmasia? as but parts of the diseased condi- 
tions. Practically, the fever bears the same relation to the local 
symptoms as does fever to pneumonia, rheumatism, synovitis, 
enteritis or cerebritis. Possibly, where a patient dies in forty- 
eight or sixty hours from great intensity of the fever, with hem- 



712 The Puerperal State. 

orrhage or convulsions, a post-mortem examination might 
reveal little or no local disorder. But such cases, we think, will 
be found an exception to the very general rule of an intimate 
association between the fever and the local trouble. In cases of 
fever from traumatism we suspect the local difficulty may have 
precedence of any febrile appearance. 

Duration. — This violent group of symptoms usually reaches 
conclusions from the sixth to seventh or tenth day. By or 
about the sixth day the symptoms abate and the patient reaches 
convalescence, or she dies suddenly under a collapse. In excep- 
tional cases neither death nor recovery takes place at the 
periods indicated, but a series of troubles may follow in the 
form of abscesses, fistula?, sinuses, dropsies, decubitus, debility 
or dementia, dragging their slow T length along over many weeks 
or even months. Such a case we had recently in private practice, 
with all the above complications continuing for nine months 
with recovery. 

Diagnosis.— The symptoms are ordinarily so bold and pro- 
nounced as to make diagnosis easy and certain. There is a 
small group of symptoms frequently occurring about the period 
of the setting up of lactation, that may sometimes give a little 
temporary anxiety to both patient and physician. But some 
suitable homeopathic remedy that may be indicated for the 
fever, with moist heat, in any convenient form applied locally 
over the abdomen, with full hot-water irrigation of the intes- 
tines, will banish this condition of affairs very speedily and so 
set matters all right. 

Prognosis. — Under the most favorable surroundings, includ- 
ing skill and experience in medical attendance, it must be con- 
fessed that the outlook is not safe or certain. In an epidemic 
form, the mortality has sometimes been fearful. The prognosis 
now under homeopathic treatment is usually favorable, but in 
case of an epidemic it must be guarded. 

Prophylaxis. — Under this head the matter of supreme 
importance is perfect cleanliness on the part of the patient and 
all in attendance upon her. Previous to making a vaginal 
examination, the accoucheur should wash his hands in warm 
water, with soap, always using a nail-brush, and moisten them 
afterwards with a weak solution of sublimate, boroglyceride, 
listerine, salicylic acid, carbolic acid or creolin. 

We prefer creolin — one to two per cent, solution. It is a 
germicide and said to be equal to sublimate, without any 



Puerperal Fever. 713 

dangers of the latter. Of course all instruments in use, sponges 
and utensils that come in contact with the patient, should have 
the same attention as the hands. Every hospital should have 
a sterilizing oven, where all the clothing, bandages, etc., that 
come in contact with the patient, should be heated and thor- 
oughly sterilized, so that no germs may exist. 

I have recently had a very satisfactory experience in the use 
of the "accouchement sheet" for the protection of the bed 
during labor. It is very comfortable for the patient, soft as 
wool and about the thickness of two ordinary comforters. It 
comes in sheets large enough to cover the bed, and is known as 
"wood wool." It is not expensive and answers a most admi- 
rable purpose, being waterproof on the under side ; is porous, 
antiseptic and absorbent on the upper surface. After the com- 
pletion of labor this antiseptic accouchement sheet may be 
removed and burnt, and the mother has her mattress not in the 
least soiled ; comfort is thereby insured and the risk of puerperal 
disease greatly lessened. 

As a further precaution in the antiseptic line, I have the vulva 
thoroughly sponged with some mild detergent application at 
least three times per day. Should there be a free disagreeable 
lochia, I have the vagina irrigated with a warm solution, in mild 
form, of some one of our admirable antiseptic preparations 
already mentioned. I have in former years employed corrosive 
sublimate, 1 to 5,000, boroglyceride, carbolic acid, listerine, and 
last, but not least, calendula. I have recently had very satis- 
factory results from a solution of creolin used locally (one to 
tAvo per cent., or about one teaspoonful to the pint of water). 
Where there are any suspicious indications or surroundings, to 
prevent the introduction of septic germs I advise a pad or pack 
of antiseptic cotton, first made moist with the solution of 
creolin, to be kept constantly applied to the entire vulva. 

Some practitioners prefer to use a pad of sublimate gauze, 
and we have employed it formerly before the discovery of 
creolin. The pad should be changed whenever it is soiled. The 
necessity or propriety of washing out the uterine cavity must 
be determined by the circumstances in the case ; it should never 
be trusted to the nurse, but must be cautiously performed by 
the physician. The infection of puerperal fever may propagate 
itself, or it may have come from external contagion, and all of 
the above precautions are of more or less value in any case of 
labor. But should the puerperal patient be in the neighborhood 



714 The Puerperal State. 

of any infectious disease, they are absolutely indispensable. No 
practitioner who has under treatment a patient with infectious 
disease should ever allow himself to take charge of a case of 
labor. 

Under the head of Prophylaxis we desire to say that in the 
near future the large lying-in-hospitals, now the boast and 
pride of our great cities, must give place to a series of one-story 
cottages, located in rural districts. They should be constructed 
of iron or other non-combustible material to guard against fire, 
with room for not more than six patients ; should be heated by 
steam or open-grate fires, and not by stoves or furnaces. Every 
such hospital should also have a sterilizing oven, so that the 
complete modern details of a perfect antisepsis may be carried 
out. Each cottage should be entirely separate from its neigh- 
bors, and should have a labor room adjoining, from which, 
after labor, the patient may be conveyed to her place in the 
cottage. With the present facilities furnished by street cars, 
railroads, telegraphs and telephones, correspondence and atten- 
tion at a distance of five to ten miles in the country could be 
accomplished with the utmost dispatch and facility. ' 

Post-mortem Appearances. — Upon opening the abdomen 
there will be found a most conspicuous display of lymphy exuda- 
tion from the entire peritoneal surface ; it is thick and heavy, 
and, if the case shall have attained five or six days' duration, 
may present signs of partial organization. The viscera are all 
glued together in a most grotesque and striking condition. In 
violent and malignant cases the parts may show signs of gan- 
grene and disintegration. 

Treatment — Aconite. — Fever that sets in with a chill ; the 
fever is of a high grade, like a real synochal fever, with dry skin, 
hard pulse, great thirst, shooting pains in the abdomen and 
uterus, abdomen very sensitive to pressure. Predicts the hour 
she will die. 

Belladonna.— Pains and fever set in suddenly; throbbing 
headache ; face red and hot ; eyes red ; throbbing of the carotids 
and indications of cerebral congestion ; patient delirious ; indi- 
cated when the delirium is furious. Dr. Hughes recommends it 
for peritoneal complications, and Baehr suggests its use for the 
above symptoms with vomiting. 

Arsenicum alb. — Sudden sinking of the strength; cold per- 
spiration, great thirst for small quantities of water at short 
intervals, constant vomiting, restlessness, anguish, fear of 



Puerperal Fever. 715 

death, a tired feeling-, which is soon followed by extreme 
exhaustion, showing evidences of a rapid change in the blood, 
a toxic condition from the catalytic effect of the blood-poison 
being diffused through the whole system. 

Yeratrum alb. — Vomiting and diarrhoea ; extremities cold ; 
lochia suppressed. Hippocratic countenance; breath cold, 
collapse threatened. May be used after arsenicum, or in 
some cases given in alternation. Compare also carbo veg., a 
keynote for which is, much flatulence, relieved bj eructation, 
generally better after being fanned. 

Baptisia. — Useful in the early stage ; tongue white with red- 
dish papillae, foetid breath ; patient delirious, sensitive in the 
iliac region; all the secretions are offensive, especially sweat 
and urine, with frequent attacks of faintness and exhaustion. 

China.— Painless diarrhoea, involuntary stools, frequent 
eructations, which give no relief. 

Muriatic acid.— Low form of fever, when it is really adynamic ; 
patient has stupid delirium, intermittent pulse, and frequent 
discharges from the bowels, with tendency to slide down in the 
bed ; deep respiration with sighing and groaning ; paralysis of 
the urinary and intestinal tract,— involuntary discharges from 
both; excessive prostration, indicating unmistakabty that 
patient is in an extreme condition; breath foetid, lining of the 
mouth inflamed, and patient apparently near her end. 

Bryonia. — An important remedy, especially in early stage; 
patient restless ; has a headache, pain in the limbs ; all of the 
symptoms are aggravated by the slightest motion; there is 
constipation. 

Rhus tox. — Low form of the fever, great restlessness, relief 
for awhile, worse at night ; slow fever and dry tongue. This 
remedy is indicated in some cases in alternation with bryonia. 

Yeratrum Yiride. — Many years since we gave reratrum viride 
tincture, in two or three drop doses, in the commencement of 
the fever, when there was a sudden rise of the pulse (120) and 
accompanied with weakness. Simultaneous with veratrum, we 
gave the patient stimulant doses of whisky and carefully 
watched the effect. We certainly found the best results from 
the occasional and cautious use of these two remedies. 

Quinine. — In certain cases, we have found quinine indispensa- 
ble. When we have an unmistakable intermittent complication, 
ushered in suddenly with a chill, followed soon after by a sweat, 
and such a reaction as to indicate that the patient will, at the 



716 The Puerperal State. 

expiration of twenty-four hours or sooner, have a repetition of 
the paroxysm, a few doses of quinine will, in many instances,, 
entirely break the attack. 

The dose of quinine may be two or three grains every two 
hours until some twenty to thirty grains shall have been 
taken. 

Gelsemium— This is an important remedy, and is especially 
useful when the case is of an intermittent variety ; the patient 
has nervous chills, the effect of emotional excitement or depres- 
sion. 

Antipyrine. — In exceptional cases, this remedy may be use- 
ful, where patient has high fever in the morning, wants water,, 
and has a dreadful headache, with pain in the frontal sinuses. 
Dose, five grains every two hours until about four doses shall 
have been given. 

Phenacetine. — This remedy is a reliable antipyretic, and may 
be used where the patient complains of great pains in the 
limbs, with headache, and fever with restlessness, and when 
other medicines have failed. It is a remedy much safer than 
antipyrine, and may be used in doses of from four to six grains 
every two hours. 

Oleum tereb. — Great tympanitis with eructations, foetid 
diarrhoea, diminished secretion of urine, hemorrhage from 
the bowels, bloody albuminous urine; tongue smooth, red 
and shining. It may be applied externally for the tympanitis, 
and abdominal tenderness, by means of stupes. Saturate a 
piece of spongio-pilline with the turpentine and apply it over 
the abdomen. Internally, it may be taken in doses of three to 
five drops, either in hot milk, or gum arabic emulsion. 

Mercurius cor. — This remedy has been recommended in 
puerperal cases where we have the development of septic in- 
fection. There is catarrhal inflammation of the bowels, with 
bloody, slimy stools, which are offensive and frequent. There 
is soreness at the pit of the stomach, tongue red and sore, urine 
scanty or suppressed. A key note for it is, involuntary stools, 
with nausea, and pains and tenesmus in the rectum. It fol- 
lows aconite well, and may be given when indicated, in alterna- 
tion. 

Nux vom. — Pain as if bruised in neck of uterus, pain in 
small of the back, when patient turns in bed. When metritis 
affects the patient, Dr. R. Hughes says, it is especially indi- 
cated. 



Puerperal Fever. 717 

Hyosciamus. — The fever assumes a typhoid form with furious 
delirium, patient apathetic, or its opposite very excitable; 
cannot sleep. 

Apis mel., arnica, ipecac, Pulsatilla and stramonium may 
all be called for, and the practitioner can select them whenever 
indicated. 

Diet.— In this disease, I prefer milk, beef-broth, clam-juice, 
Mosquera's beef-cacao, toast, buttermilk, and such other nutri- 
tious food and drinks, properly selected, as the patient desires. 

The following we have used for several years when nothing 
else could be borne : Take the whites of two eggs and put them 
into a bottle with two ounces of lime water. Shake the contents 
for at least five minutes. Now add half a pint of new milk, and 
shake well again; finally, a little sugar, sherry wine and nut- 
meg may be added, to suit the patient's taste. I can speak of 
this preparation in the highest praise, and often prescribe it in 
general practice, for a variety of serious ailments. 

Carbonic-acid water from a syphon bottle will be found very 
grateful to the patient, and greatly alleviates thirst and nausea. 
It may be given at any time, and will not interfere with the 
remedies prescribed. Frequent draughts of hot water should 
be given for the nausea; they will be found to give material 
relief. 

Alcoholic Stimulants.— In malignant forms of puerperal fever, 
I would especially recommend alcoholic stimulants to be given 
freely. I have used stimulants for the last ten years, and take 
occasion to state that clinical experience has confirmed me in 
their utility and safety. If the stomach bears the stimulant 
badly, administer it hypodermically, or with milk by enema. In 
the worst forms of puerperal septicaemia, as likewise in malig- 
nant scarlet fever with a temperature of 105° F., pulse of 120, 
or more, give whisky every hour or two, to keep up the strength 
and to assist nature in eliminating the poison. It has been 
proved by physiologists that alcohol under certain conditions 
possesses an antipyretic action. It cannot be relied upon to 
abate ordinary febrile excitement, but we have much clinical 
experience to prove that it moderates septic fever. We know 
that alcohol lessens the oxidizing tendencies of the red cor- 
puscles of the blood, diminishes the sensibility of the brain and 
nervous system, and renders the poison of septicaemia and 
scarlet fever less intense and energetic, so that it cannot act so 
deleteriously as it does when no alcohol is administered. 



718 The Puerperal State. 

The celebrated German physiologist, Moleschott, says in his 
quaint language : " Alcohol is the savings bank of the tissues." 
I know from experience that alcohol acts favorably against the 
inroads of necrotic processes, such as we are liable to have in 
septicaemia, scarlatina and diphtheria. The administration of 
alcohol in puerperal sepsis seems to have been first employed 
by Professor Breisky, of Vienna, and later was taken up by 
Runge, and recently by Dr. Martin, of Berlin, who especially 
recommends it. Martin advises alcohol to be given in the form 
of cognac, rum, Burgundy or Bordeaux wine, and champagne. 
He insists upon the most concentrated food. He says it fre- 
quently requires energetic persuasion on the part of the physi- 
cian and attendants to induce patients to take spirituous 
drinks, which often have to be changed. 

When diarrhoea occurs, alcoholic stimulants must be given 
with a little caution, and changed frequently. The effect of 
alcohol consists in strengthening the heart's action, and in the 
increase of the resisting power of the individual against the 
ravaging action of the infection. 

Where we have peritonitis in puerperal disease, with great 
agony, I am certain of having saved lives and brought relief 
by an occasional hypodermic injection of morphine. 

In some cases the pains are so intense that humanity dic- 
tates we should give temporary relief by a hypodermic. In my 
experience I have never seen anything but good results from its 
judicious use. We must bear in mind that we have a fearful 
disease to combat, and that it is our duty to do everything to 
alleviate as well as to cure our patient. Hot water applications 
give great relief. The condition of the bladder should be care- 
fully watched, and the urine drawn off whenever it cannot be 
passed naturally. I have seen in practice, more than once, the 
case of a distended bladder mistaken for a metritis. The proper 
diagnosis of the case saved the life of the patient. In one case 
nearly two quarts of urine were evacuated by the use of the 
catheter, followed by immediate relief and rapid convalescence. 

In consultations, especially with midwives, and young physi- 
cians, I have occasionally found the bladder of a puerperal 
woman entirely neglected, and as soon as the urine w T as drawn 
the patient at once improved. 

Use of the Curette. — In some cases of puerperal diseases 
attended by fever, where there is a bad smelling discharge from 
the uterus, with all the symptoms of a metritis or metroperi- 



Puerperal Fever. 719 

tonitis and impending septicaemia, we may find that portions 
of the placenta have been retained. In such cases curettement 
is necessary. Introduce the blunt curette, having previously 
covered it with iodoform, and carefully remove any remains of 
the placenta that may have been retained. Sometimes (per- 
haps in the majority of cases) it may be necessary to use the 
sharp curette, if there are pieces of the placenta situated high 
up which cannot be detached with the blunt curette. 

After the curette, use an intra-uterine injection of hot water 
and thymol, 1 to 1,000, or creolin, one per cent., or any other 
antiseptic such as we have mentioned, except sublimate, which, 
in this special case, we use only in a solution of 1-10,000. After 
this, the vagina should be lightly packed with iodoform gauze, 
that may be repeated for a day or two, or longer, which will 
keep up a safe drainage. The iodoform gauze should be con- 
tinued until the offensive odor has quite disappeared. 

Refrigeration. — This may be effected handily by applying 
cold water compresses over the abdomen, or what is still more 
practical for reducing the temperature, we may use the cold- 
coil, known as Letter's Vienna coil. This may be filled with iced 
water, and applied over the abdomen. 

Kefrigeration is to be used especially in cases of very persist- 
ent fever that seems to have baffled all other remedies. 

Conclusions.— 1. Puerperal fever, or toxaemic puerperal dis- 
ease, is peculiar to the lying-in woman, and therefore appropri- 
ately named. 

2. The essential causes of the disease may be unknown to us ; 
but we know that there must be some abnormal conditions of 
the blood, together with epidemic influences, namely, external 
infection, psychic conditions, emotions and shock. Traumatic 
injmies coming from lingering and instrumental labors may 
singly or conjointly favor the development of the disease. 

3. Puerperal fever may be so severe as to exhaust the patient 
rapidly and terminate with death within two to four days, and 
fatal cases may happen in obstetrical practice called "sudden 
death," where it is impossible to discover the exact cause of the 
infection or its location. 

4. Local inflammations may affect women in confinement, 
without puerperal fever. 

5. We agree with the late Professor Fordyce Barker, that 
septicaemia may be developed in puerperal women either from 
autogenetic or heterogenetic infection, without puerperal fever ; 



720 The Puerperal State. 

but such an infection is usually a complication of puerperal 
fever. 

6. If it be true that puerperal fever is an essential disease, then 
we shall have to concede that a specific zymotic and contagious 
disease may, under certain circumstances, follow parturition. 
(It should, therefore, be the duty of every obstetricist to give 
the patient he is engaged to attend, careful advice to observe 
the rules of hygiene, to avoid contagion, and to take a well 
selected and nutritious regimeu,so that her constitution may be 
prepared and fortified to undergo the trials she will be subjected 
to during the puerperium.) 

7. The opinion current among some of the profession, that 
puerperal fever occurs only after severe labors, is not true. In 
some cases it sets in insidiously, after a normal and easy labor, 
and this apparently proves that women in confinement are 
peculiarly sensitive to certain unknown noxious influences that 
may favor the development of an essential fever, zymotic in 
character. 

In as brief a manner and as clearly as possible I have en- 
deavored to give the facts of the subject matter of child-bed 
fever 

I trust, that it may prove as interesting to the profession as 
it has been to me 

I have my own practice and experience for many years to 
guide me, and have studied with some care the best authorities 
on the subject. Ever glad to learn whatever has been proved 
by others, I claim to be only a student still. Few things are 
more wonderful than the great advances being made in the art 
and science of medicine. 



APPENDIX. 



ANTISEPTIC MIDWIFERY. 

By L. L. Danforth, M.D. 

Antiseptic midwifery, as this subject is understood at the present time, 
presents in the development of its history most remarkable phases. 

Its origin dates from the efforts of Semmelweiss in 1847* to reduce the 
fearful mortality which everywhere attended the lying-in of women, espe- 
cially in the large Maternities of the world. 

From this beginning the doctrine has extended and has wrought such 
remarkable results that its discovery and promulgation may justly be 
ranked in beneficence to mankind next to Jenner's discovery of innoculation 
for the prevention of small-pox. 

In order to understand the full import of this assertion, we must review 
the history of midwifery with respect to the mortality from the so-called 
puerperal fever, for it is in its relation to the prevention of this dread 
disease that antisepsis has acquired its highest usefulness. 

Beginning at so remote a period as 1664 in the Hotel Dieu in Paris — the 
most ancient epidemic of which we have any history — down to the last 
decade, the mortality among lying-in women was simply appalling. In 
the Maternity Hospital of Paris the mortality in 1866 was 11.6 per cent., 
and in 1864 20.3 per cent., and for ten years from 1860 to 1870, it averaged 
9.6 per cent.t 

* From Paul Bar's "Antiseptic Methods in Obstetrics," (Paris, 1883) we learn that Har- 
vey practiced intra-uterine injections in cases of retained placenta. Recolin (1757) pro- 
posed intra-uterine injections of warm water. Levret (1786) wrote: "If there be any 
putrefaction I obtain its discharge and that of the foreign substance (placental fragments) 
by means of aqueous injections made into the cavity of the womb ; and I find it very 
useful." But these writers did not possess correct information as to the nature of puer- 
peral infection, and they had no conception of the true antiseptic method. Dr. Oliver 
Wendell Holmes, in a paper entitled "Puerperal Fever as a Private Pestilence, "published 
in 1843, called the attention of American physicians to the contagiousness of child-bed 
fever, and laid down rules for the guidance of the practitioner which if followed would 
tend to the limitation of this disease. If Dr. Holmes had never done anything but this 
to merit the gratitude of his countrymen, his efforts in this direction should be made an 
everlasting monument to his memory. He says: "1. A physician holding himself in 
readiness to attend cases of midwifery should never take any active part in the post-mor- 
tem examination of cases of puerperal fever. 

"2. If a physician is present at such autopsies, he should use thorough ablution, 
■change every article of dress, and allow twenty-four hours or more to elapse before 
attending any case of midwifery. It may be well to extend the same caution to simple 
cases of peritonitis. 

"3. Similar precautions should be taken after the autopsy or surgical cases of erysipe- 
las, if the physician is obliged to unite such offices with his obstetrical duties, which is 
in the highest degree inexpedient." 

+ Bar. Paris, 1883. 

(46) 



722 Appendix. 

In the Prague Maternity the mortality in 1865, was 9.28 per cent. ; in 1869, 
11.62 per cent. 

It was such statistics as these which led Fritsch to exclaim : "To be 
laid on the bed of confinement was equal to being delivered to the hang- 
man."* 

During the six years prior to the advent of Semmelweiss in the Vienna 
Obstetrical Clinic the mortality was 9.92 per cent. As a result of the im- 
proved methods under this obstetrician the mortality dropped to 1.27 
per cent. 

Semmelweiss was led to the adoption of the measures which wrought 
this remarkable change by observing that the mortality occurred in the 
wards reserved for physicians only, while in those attended solely by mid- 
wives the mortality was comparatively small. He furthermore noticed 
that the fatal cases occurred in healthy primiparse with a protracted first 
stage ; many of their children also dying, and showing the same post-mor- 
tem changes that were found in the mothers. Women who were confined on 
their way to the hospital and afterwards detained there, as well as the 
cases of premature labor, in which there were few or no examinations 
made, were rarely sick. The increased mortality in the wards attended 
by physicians he attributed to the fact, that the medical students who were 
engaged in dissections and the post-mortem examinations visited these 
wards, examined the patients, and thus conveyed the poison from which 
the disease developed. The ordinary cleansing with soap and water was 
not enough to take away all contamination, as the odor clinging persist- 
ently to the fingers showed. He ordered at once that a remedy be used 
to destroy these putrid matters, that the hands be washed with chlorine 
water, or with chloride of lime ! The result was the diminution of the 
mortality from nearly 10 per cent, to a trifle over 1 per cent. ! 

Basing his conclusions upon the remarkable results obtained by the 
adoption of the new method, Semmelweiss advanced the doctrine that 
puerperal fever was due to the introduction of poison from an external 
source, mainly from the absorption of putrid animal substances-: he be- 
lieved also that it might arise in rare instances from poison engendered 
within the body of the woman herself, by the spontaneous decomposition 
of lochia, retained fragments of decidua, of blood coagula, of necrosed tissue, 
or in consequence of severe instrumental labors. In other words, that 
this so-called puerperal fever was no new specific disease, but a variety of 
pyaemia. This was in opposition to the generally accepted belief that 
puerperal fever was an essential fever, as much so as typhoid fever, or 
typhus fever, and peculiar to child-bed. 

It would be supposed that a method which had accomplished so much 
in the diminution of mortality among lying-in women would be hailed by 
all as the greatest boon that could be conferred upon afflicted humanity. 
Like other discoveries of importance to mankind, particularly in the 
sphere of medicine, opposition at once met the promulgation of the new 
doctrine. 

Some there were like Rokitansky, Skoda, Hebra, and Simpson, t in Edin- 

* Grundziige der Pathologie und Therapie des Wochenbetts, 1884. 

+ Simpson said they had long known in England what they stated as new in Vienna. 
The assertion was probably based on Denman's statement that puerperal fever could be 



Antiseptic Midwifery. 723 

burgh, who upheld it. But Scanzoni, Kiwisch, and Seyffert in Germany- 
were opposed to it, and talked violently against it. The Paris Academy of 
Medicine decided unfavorably upon it, and even in Germany there was 
more scepticism than belief. Virchow as late as 1864 before the Berlin 
Obstetrical Society declared himself positively against Semmelweiss' the- 
ory of infection from outside, as regarding the epidemic propagation of 
puerperal fever. "Just as well," he says, "as an anthrax may originate 
spontaneously in an animal, may puerperal fever do the same in the deep 
cellular tissue of the female pelvis." 

The late Dr. Fordyce Barker in his classical work upon the Puerperal 
Diseases (1874), and in his later writings and utterances, was the most 
active opponent in this country of the now accepted doctrine concerning 
the origin and prophylaxis of puerperal fever. 

The researches of modern scientific investigators, as carried on by 
Pasteur, Koch, Doleris, and others, have borne out the earlier theories of 
Semmelweiss. As a result of these researches scientists are now able to 
formulate certain principles relating to septic and purulent infection, 
which we may accept as established facts. 

1st. The so-called puerperal fever, or according to the new nomencla- 
ture, puerperal septicaemia, is a disease characterized by the invariable 
presence in the organism infected of minute bodies generally termed 
bacteria. The common germs of suppurative wounds are the staphylococcus 
pyogenes aureus, the staphylococcus pyogenes albus, and the streptococcus 
pyogenes. These germs invariably come from without, and are never developed 
de novo in the body of the affected woman. 

2nd. While the entrance and development of micro-organisms within 
the body is usually the cause of the symptoms observed, these bodies are 
not absolutely essential to the production of the morbid processes. 

The products of bacterial activity, the ptomaines or the leucomaines 
(the result of putrefactive changes in animal tissues closely simulating 
vegetable alkaloids) are equally deleterious to the health of the organism. 
These poisons may produce the changes to be observed, although these 
products do not and cannot occur without the previous growth of the 
organisms which give rise to them. 

The symptoms may therefore be due to a double cause ; the growth of 
the bacteria, and the overwhelming of the system by their numbers, or the 
toxic effect of the alkaloids produced in the course of their growth; and 
these two influences may act independently or together. 

As a result of the improved methods of treatment based upon the recog- 
nition of the truth of these propositions, the vital statistics in the Mater- 
carried from one patient to another by doctors and mid-wires, and that the poison was 
the same as that producing the acute exanthemata, though he believed also that there 
were other etiological factors capable of producing it. Certain it is that in England, long 
before the doctrine was received elswhere, most physicians believed in the contagious- 
ness of puerperal fever. It was the custom long ago to isolate the sick, and the attendance 
at private houses was so well organized that is was exceptional for a puerperal patient 
to be conveyed to the Maternity for treatment. In the Dublin Maternity from 1850 to 1854, 
the mortality ranged from 0.56 to 0.89 per cent. But no one suspected the full import of 
Denman's suggestion. Simpson in 1850 published a paper "On the Analogy Between 
Puerperal and Surgical Fever," in which he admitted the indentity of puerperal and sur- 
gical fever. This article is well worthy of perusal at the present time, and accords in 
many respects with the modern doctrine concerning the origin of puerperal fever. 



724 Appendix. 

nities of the world have been entirely revolutionized. In private practice 
the results have not been so striking because physicians have not univers- 
ally adopted the teachings of modern science as they should have done. 
Improvement in this respect is however going on, and we may expect to 
see septicaemia practically stricken from the list of puerperal diseases, as 
soon as physicians will take the necessary precautions to exclude disease- 
producing germs from the bodies of their puerperal patients. No greater 
proof of this assertion is needed than to refer to the statistics of some of 
the leading Maternities in this country and in Europe. 

In the Tarnier pavilion connected with the Paris Maternity every 
woman who comes to be confined occupies a room completely isolated dur- 
ing the whole period of her lying-in until she is entirely recovered. Here 
the antiseptic method was rigidly enforced from 1876, with six deaths from 
1876-79 (inclusive). From 1880-83 there were no deaths and only eight 
cases which could be called septic in character. According to Galabin* of 
London the rate of mortality in English Maternities since the use of 
antiseptics is two to one thousand instead of the former rate of ten to one 
thousand (total mortality); deaths from septicaemia or pelvic inflammation 
1.5 to 1000. The number of cases in which slight elevations of temperature 
occur after delivery has fallen off one-half. 

Slawjanski,f of St. Petersburg, reports the morbidity and mortality in 
fifty-two institutions in Russia, representing 21,280 labors. Repeated ele- 
vations of temperature were observed in 6.9 per cent., and the mortality 
from puerperal diseases was only 0.28 per cent. 

To Dr. Henry J. Garrigues of New York City is due a large share of the 
credit for the advance which has been made in this country in the manage- 
ment of lying-in hospitals, and also in private practice, with reference to 
the adoption of antiseptic measures. His monograph on "Antiseptic Mid- 
wifery " i should be read and pondered by every practical obstetrician. As 
an example of the results accomplished by Dr. Garrigues, the mortality in 
the Maternity Hospital Blackwell's Island New York City affords a most 
striking illustration. From October 1, 1882, to October 1, 1883, under 
the old regime, 447 patients were confined, with a total mortality of 6.71 per 
cent., while for the nine years from 1875 to 1883 (inclusive) the total mor- 
tality was 4.17 per cent. 

Under Dr. Garrigues from 1884 to 1888 (inclusive) there were 2,271 
deliveries, with a total mortality of twenty-four (1.06 per cent.) ; only six of 
this number, or 0.27 being due to sepsis. In the years 1885 and 1888 there 
were no deaths from sepsis. 

The change in morbidity is no less remarkable than' the reduction in 
mortality. Very few of the puerperse were sick under the improved 
regime, and those who were ill only slightly so. 

In the Boston Lying-in Hospital the change has been no less remark- 
able. The mortality from sepsis from January 1, 1882, to December 31, 
1882, 288 patients, was 5.55 per cent. 

Dr. Wm, L. Richardson reduced the mortality in this Institution during 
the period from January 1, 1886, to December 31, 1886, 373 confinements, .0 
per cent. 

* Transactions Tenth International Congress (Berlin, 1891), 

-r Ibid (Berlin, 1891). 

X Published by Geo. S. Davis, Detroit, Mich., 1886. 



Antiseptic Midwifery. 725 

In the Sloane Maternity * in New York City, the mortality from septi- 
caemia was one case in one thousand successive confinements, and this 
patient was admitted in the second stage of labor, in a most filthy condition, 
having been examined at her home, and from her symptoms and tempera- 
ture was believed to be in a septic condition when she entered the hospital. 

Such statistics as have been quoted must have a powerful influence in 
impressing upon the minds of practical obstetricians the necessity for the 
utmost care in the management of their puerperal cases. It should be the 
duty of every one thus engaged to make himself familiar with the sources, 
nature and prevention of septic infection. 

Treatises on bacterio]ogyt afford much information relative to this sub- 
ject, which is interesting and of an exceedingly practical nature. 

It is only by an appreciation of the relation to practical midwifery of 
these comparatively recent additions to human knowledge that any gen- 
uine advance can be made in the diminution and final elimination of septic 
processes from the lying-in chamber. 

The prevention of puerperal infection by strict adherence to methods of 
treatment which have for their object the exclusion of disease germs, is a 
matter of supreme importance, and the principles of this method should be 
followed with religious conscientiousness. 

We know now that the entrance of the micro-organisms into the system 
invariably occurs through the genital tract, the germs being conveyed 
thence by means of the hands or clothing of the physician or nurse, the 
instruments employed, or through the medium of the air of the lying-in 
chamber, at a time when the vagina and uterus are in a state of greatest 
receptivity. 

As a natural corollary of this fact the prevention of infection can only 
be accomplished by the adoption of the most thorough cleanliness in every 
detail of the lying-in chamber. 

As prevention is better than cure, so asepsis, viz. : the exclusion of micro- 
organisms from wounds and their discharges, is superior to antisepsis* 
which is the destruction of disease germs after they have gained art 
entrance into the body, by the use of antiseptic agents. 

Thorough cleanliness, and the destruction of disease germs before these 
organisms have had time to penetrate the deeper tissues of the body should 
be the chief aim of all engaged in obstetrical practice. 

In Germany the subject of antiseptic midwifery is made a matter of 
State regulation, especially in the practice of midwives, and similar laws 
should be enacted in this country. It should be the duty of municipal 
authorities and also of the individual physician to enlighten the laity, 
especially the poor in large cities, who live in crowded tenement houses, 
on the necessity for greater cleanliness than is ordinarily observed, in all 
that pertains to the lying-in chamber. Even though the apartment be 
small, poorly ventilated, and the preparations of the simplest character, a 
very small expenditure of money will provide such articles as are neces- 

* Report on the first series of one thousand successive confinements, from January 1, 
1888, to October 1, 1890, by Jas. W. McLane, M. D. American Journal of Obstetrics, 
April, 1891. 

f'The Etiology of Puerperal Fever," by Harold C. Ernst, M.D. American System of 
Obstetrics, Vol. II, p. 401. 



726 Appendix. 

sary to enable the physician to carry out the details of the antiseptic 
treatment in a very satisfactory manner. A few words from the medical 
attendant as to the benefits to be derived from these simple precautions, 
will in most instances enlist the cooperation of the patient and her friends, 
and such articles as are needed will be cheerfully procured. The effect of 
these precautions will unquestionably be a marked diminution in both 
morbidity and mortality among puerperal women. 

The physician himself should always remember that puerperal septi- 
caemia is a preventable disorder, and that its occurrence betokens some 
neglect in attention to those details of personal or general hygiene whereby 
the genital tract becomes infected. 

Self-infection (auto-genetic) is impossible in the light of our present 
knowledge of bacteriology. We cannot admit that the patient can pro- 
duce any poison herself. The wounds in the genital tract, a retained 
blood-clot, a piece of placenta, or a shred of membrane in her uterus, afford 
a most favorable soil for the development of the microbes, but these must 
come from the outside (hetero-genetic infection). 

It is possible that germs may have found lodgment in the genital tract 
of the woman before labor came on, and in this sense we may admit auto- 
infection. But so long as the mucous membrane of the genital tract 
remained intact, no harm could be done, for the germs formed no part of 
the organism of the patient ; they were foreign bodies, ready to do their 
work when access to the deeper tissues was afforded them. The noxious 
germs may emanate from a variety of sources, and in proportion as these 
sources are numerous so should be the thoroughness of the measures to 
prevent their entrance to the genital tract of the patient. 

Inasmuch as it is probable that the germs may gain admission through 
the air, as well as through the medium of the hands and instruments of 
the physician and nurse, a lying-in chamber should be selected in w r hich 
the atmosphere cannot be contaminated by proximity to a sewer, a privy, 
or any decomposing animal or vegetable substance. 

If the lying-in chamber adjoins a bath-room or water-closet the door 
between the apartments should be kept closed as much of the time as pos- 
sible, and Piatt's Chlorides used to flush the was.te-pipes from all basins 
and bath-tub. 

The room, so far as practicable, should be divested of all superfluous 
furniture, and made as light and airy as possible. 

Every examination of the woman, whether in the last days of gestation, 
or during labor, should be preceded by a thorough ablution of the hands 
and arms to the elbows with soap and water, thoroughly scrubbing the 
skin, and particularly the finger-nails with a nail-brush. Dirt under the 
nails should be removed with a nail-cleaner, before the scrubbing with the 
brush and not after. To be prepared for this preliminary cleansing, the 
accoucheur should carry in his obstetric bag the articles requisite to ac- 
complish this work, viz. : — a nail-brush, a nail-cleaner, bi-chloride of mer- 
cury tablets (Wyeth's), and, on account of its superior cleansing qualities, 
an ounce jar of Sapo Viridis* (the green soap of the German Pharmacopoeia), 
which any pharmacist can supply. * 

* The soft potassa soap made in this country, though perhaps not possessing the same 
germicide power as the German, is much superior to the hard soda soap in common use. 



Antiseptic Midwifery. 



i'^i 



The latter is to be used instead of the ordinary soap commonly used in 
the household. The use of the green soap is especially valuable in cleans- 
ing the hand and removing germs situated in the deeper layers of the skin, 
in case one has been dressing a wound or attending a case which could by 
any chance give rise to infection. 

After washing the hands and arms in the manner described, they 
should be soaked for three minutes in a solution of bi-chloride of mercury 
[1-1000), in which the scrubbing may be repeated. 

If the accoucheur has been in attendance upon a case of any of the 
zymotic diseases, or a case of puerperal septicaemia, or upon a surgical case 
of a septic nature, or upon any other disease liable to infect the patient, 
he should before going to the lying-in room take a full bath containing one 
or two drachms of the bi-chloride of mercury, being particular to wash the 
hair and beard while in the bath. His clothing should be changed through- 
out. Before examining the patient the preliminary cleansing of the hands 
and arms should be carried out with extraordinary thoroughness. Unless 
the accoucheur who has been exposed to contagion can spend the time to 
perform these necessary ablutions, and change his clothing, it is his duty 
to decline to attend the case.* 

* Recent researches by Howard A. Kelly. M. D. (Johns Hopkins University), on " Hand 
Disinfection" (Am. Jour, of Obstetrics. Vol. XXIV. Dec, 1891) are of great interest in this 
connection. 

Dr. Kelly's conclusions on this subject are as follows : 

I. " Staphylococci i mostly albus > were present on the hands of all persons examined." 
Sixty-five experiments were made with doctors who scrubbed their hands ad libitum | ten 

to twenty minutes i with strong brown soap and hot water frequently changed. Eleven of 
these were outside the gynecological staff. In every instance of the eleven, myriads of 
coccal colonies developed. In the remaining fifty-four cultures, taken from Dr. Kelly's 
gynecological assistants and himself, all but nine yielded numerous colonies. These nine 
are to be explained by the inhibiting power of bi-chloride of mercury used the day pre- 
vious. From these experiments Dr. Kelly concludes : 

II. " It is impossible to get rid of these staphylococci by scrubbing the hands and nails 
from ten to twenty-five minutes with a sterilized brush, soap, and water, temperature 
40" C. (104= F.) - ' 

III. "Bi-chloride of mercury solutions as strong as 1-500 are not germicidal after the im- 
mersion of the hands for from two to five minutes. The mercuric salt acts either by 
mechanically coating or chemically combining with some portion of the coccus, thus only 
inhibiting further growth until the salt is precipitated or removed." This inhibiting action 
may persist at least twenty-four hours after the last use of the drug. During this period 
attempts to develop coccal colonies by precipitation with a sterile ammonium hydro- 
sulphuret solution were futile : after that period colonies were found. 

IV. "Solutions of potassium permanganate and oxalic acid are the best germicides. Experi- 
ments have demonstrated that the permanganate of potash, applied to the hands in sat- 
urated solution, and then decolorized by a saturated solution of oxalic acid, is the most 
efficient germicide in our possession." 

Dr. Kelly's method is as follows : 

1. " Scrubbing the hands, with especial attention to the nails— not more than one milli- 
metre in length— for ten minutes, in water frequently changed, at about 40° C. (104° F.). 

2. Immersion of the hands in a solution of permanganate of potash, made by adding an 
excess of the salt to boiling distilled water, until every part of the hands and lower fore- 
arms is stained a deep mahogany red or almost black color. They are then transferred at 
once to a saturated solution of oxalic acid until completely decolorized and of a healthy 
pink color. This decolorization is accompanied by a sense of warmth, due to chemical 
reaction, and a sharp stinging wherever there is any abrasion of the epidermis. 

3. Washing off the oxalic acid in warm sterilized water. 

'• By this simple process the hands are rendered more sterile than by any other known 
means." 



728 Appendix. 

These same precautions in every detail should be enjoined upon the 
nurse. 

Instruments should be carefully scrubbed with soap and water before 
use, and then immersed in a carbolic or creolin solution of 2 per cent, 
strength. When a woman is taken in labor the nurse should be directed 
to bathe the abdomen, thighs, buttocks and especially the labia and the 
sulci near the genitals with a bi-chloride solution (1-2000). 

Antiseptic Precautions During Labor. 

In private practice it is advisable to give a creolin* douche {Y% per 
cent, strength), or a corrosive sublimate douche (1-2000), at the beginning 
of labor. 

Examinations should not be made oftener than is absolutely essential to 
note the progress of the case. During labor a bowl of the bi-chloride solu- 
tion (1-1000) should be kept at the bedside where the physician can easily 
reach it, and the patient should not be touched until the hand has been 
immersed in this fluid for a minute or more. After an examination the 
hands should be thoroughly scrubbed as in the beginning. The ordinary 
lubricants, such a vaseline, oil, lard, etc., are unnecessary and dangerous. 
The practice of anointing the imperfectly cleaned finger with vaseline, 
which has already been used for all sorts of purposes in the household, is 
exceedingly reprehensible. In fact, a lubricant for ordinary examinations 
is unnecessary. The fluid that adheres to the finger Avhen we dip the hand 
into the solution of bi-chloride or creolin, the last moment before entering 
the vagina, is all that is necessary. The same applies to the forceps and 
other instruments after rinsing in the creolin solution. 

As a lubricant for the hand and arm in case it is necessary to enter the 
vagina or uterus, employ a glycerole of carbolic acid 3 per cent, strength. 
Garrigues recommends mollin ( 5 per cent, carbolic), which looks much 
like lard, softens readily on the skin, makes the latter very slippery, and 
washes off easily. 

In protracted cases the vaginal douche should be repeated every three 
hours. In ordinary cases vaginal douches are unnecessary. After delivery 
the patient is washed scrupulously clean with the antiseptic solution, a 
hot vaginal douche (bi-chloride 1-4000) is given, all soiled clothing 
removed, and the bed arranged with everything clean throughout. 

Intra-uterine injections (hot creolin or carbolic solution, 2 per cent.) 
are advised in every case in which it has been necessary to introduce the 
finger, the hand, or instruments into the interior of the womb. For this 
purpose the physician should possess and always carry in his obstetric bag 
with the other articles previously named, a long glass tube (Chamberlain's 
tube) curved like a male catheter, with openings at the sides and end; 
this should be attached to the tube of a fountain syringe. This tube 
should be passed to the fundus and the direction and distance should be 
determined by the external hand on the fundus. It is of course under- 

* Creolin (a coal tar derivative) gives results fully as satisfactory in ordinary cases as 
those of corrosive sublimate, and is a better deodorizing agent than carbolic acid or the 
sublimate; it is also safe for intra-uterine irrigation, and possesses an oily consistency 
which renders it especially good for hands, arms, and instruments. Creolin may be em- 
ployed in the strength of 2 per cent, (about two drams to the pint), and it makes a better 
solution if mixed with cold water first, and afterwards placed in the hot water. 



Antiseptic Midwifery. 729 

stood that preventive antiseptic treatment, apart from gynecological 
considerations, demands an immediate repair of ail save the slightest 
lacerations of the genital tract. After these details have all been fulfilled, 
the final douche given, and the external parts made as clean as possible, 
the occlusion dressing, in place of the ordinary napkin, is now applied to 
the vulva. 

The occlusion dressing as described by Garrigues* is made as follows : 
"The vulva is covered with a pad of absorbent cotton wrung out in the 
solution (bi-chloride 1-2000). Outside that comes a piece of oiled silk, or 
preferably thick gutta-perchat tissue dipped in the solution. The cotton 
pad should reach from one genito-femoral furrow to the other, and cover 
the symphysis in front and the anus behind. The water-proof tissue must 
go one finger-breadth beyond the pad in all directions, and is folded for- 
ward against the inside of the thighs. To keep this antiseptic part of the 
dressing in place, use a dry pad of absorbent cotton and a rectangular 
piece of canton flannel, or a square piece of unbleached muslin, half a yard 
in both directions and folded diagonally like a cravat. The ends are like- 
wise folded in, so as to obtain a rectangular bandage five inches wide and 
about fourteen inches long, which is pinned with four pins in front and 
two behind to the binder, so as to fit the parts tightly. This dressing is 
removed in the morning, the afternoon, and the evening. The patient 
passes her urine spontaneously, or if she is unable to do it herself, it is 
drawn with the catheter. A stream of lukewarm solution is directed by 
means of a fountain syringe over the outside of the genitals and the 
adjacent parts, and a fresh dressing is applied." 

If cheapness is desired, ordinary cotton batting can be used instead of 
the absorbent cotton, but it does not absorb the discharges so readily, and is 
more bulky than the absorbent cotton. 

Antiseptic douches after labor are not necessary if the foregoing pre- 
liminaries have been faithfully carried out. 

The Antiseptic Treatment of Puerperal Infection. 

The first symptoms of septic infection as evidenced by chill, fever, pain 
in the uterus, distention of the abdomen, flushed face, throbbing headache, 
diminution of the lochia, do not usually occur until the third or fourth 
day after confinement. The symptoms may come on with less violence 
and are not therefore so manifestly septic in origin ; but whatever the 
mode of onset, as soon as the diagnosis is established, intra-uterine irriga- 
tion should at once be made — not by the nurse — but by the physician 
himself, with all the care of a surgical procedure. 

The long glass tube, or a double current metal catheter, should be 
passed to the fundus, and a quart of hot water (110°-115° F.) should be 
allowed to irrigate the cavity. The precaution should be observed to wash 
out the vagina before the tube is introduced into the womb, and also to 
elevate the fountain bag no higher above the bed (one foot will answer) 

* Antiseptic Midwifery, p. 50. 

i The gutta-percha tissue can he purchased in small boxes containing from one to 
three yards wherever surgical supplies are sold. It is more expensive than oiled silk, 
but preferable on account of its ligntness, though oiled silk answers an excellent purpose 
as a water-proof dressing. 



730 Appendix. 

than will cause the water to flow gently but steadily. The cervix is at this 
early stage after confinement always so open as to permit the easy outflow 
of the fluid. 

Simple boiled water would no doubt suffice in most cases to accomplish 
the desired result, which is to flush the uterine cavity of all debris and 
decomposing material, just as we apply the principle of drainage and irri- 
gation to a septic cavity elsewhere in the body. To make the irrigation 
more effective, however, it is safer to use an antiseptic. Creolin. \% to 2 
per cent, strength, or permanganate of potash (2 to 3 per cent.), are prefer- 
able to carbolic acid or the bi-chloride of mercury for irrigation of the 
interior of the womb. To obtain the best result the intra-uterine douche 
must be used early, since by absorption the deeper tissues and the blood 
soon become affected, and then local measures are comparatively ineffi- 
cient. The mercuric salt is employed by many obstetricians in the 
strength of 1-4000, for intra-uterine irrigation, but its use is attended by 
some danger, and lives have been lost from poisoning by the remedy in the 
strength of 1-4000 when injected into the uterus. If the kidneys are 
affected its use is positively prohibited. After an intra-uterine injection 
of any kind, the fluid should be squeezed out of the uterus and vagina by 
uterine pressure, and by turning the patient on her side. The irrigation 
should be repeated every four to six hours depending on the symptoms. 
This radical procedure may be considered unnecessary by some, but the 
good results obtained by it are too obvious to be questioned, or to need any 
defence. It would seem to be more rational to strike at the origin of the 
poison at once, than to rest content with vaginal irrigation which can only 
wash away the drainage, and leaves the source of the infection uncleansed. 
It is better furthermore to resort to this operation early, before septic in- 
fection has taken place to a serious degree, than to delay until the poison 
has passed beyond the reach of local disinfectants. 



INDEX 



Abdomen, Changes in, caused by 

pregnancy, 99, 117. 
disturbance of contained organs 

from pressure during pregnancy, 

100. 
enlargement of, during preg- 
nancy, 92. 
flattening of, during pregnancy, 

92. 
formation of, 67. 
form of, in pregnancy, 106-107. 
form of, in hydramnios, 197-198. 
in embryo, 67. 
palpation of, in diagnosis of 

pregnancy, 108-109. 
permanent changes in, caused by 

pregnancy, 103. 
Abdominal plates, 66. 
tubo, pregnancy, 141. 
pregnancy, 141. 
palpation as means of diagnosis 

of presentation, 119-120. 
Abnormalities in form of uterus, 45- 

46. 
Abortion, Acute diseases as causes 

of, 162. 
albuminuria as cause of, 161. 
use of anesthetics in, 180. 
causes of, 159-160. 
changes in decidua causing, 185- 

186. 
use of curette in, 183. 
definition of term, 159. 
diagnosis of, 168-169. 
dilatation of cervix to promote, 

175. 
methods of emptying uterus in, 

176. 
endometritis as a cause, 160-161. 
fibroid tumors as a cause of, 161. 
frequency of, 159. 
hemorrhage as a symptom of, 164. 



Abortion, hemorrhage during, Con- 
trol of, by hot water injection,181. 

hydrorrhea gravidarum causing, 
187. 

immediate causes of, 162-3. 

incomplete, 165. 

incomplete, Diagnosis of, 166. 

induction of, 594. 

induction of, in deformed pelves, 
490. 

signs of inevitable, 174. 

inflammation as a cause of, 161. 

maternal causes of, 160. 

neglected cases, 182-183. 

neuralgia as a cause of, 162. 

ovular, Cause of, 160. 

use of placenta forceps and blunt 
hook in, 182. 

placenta removed in fragments in, 
180. 

polypoid growths causing, 187. 

preventive treatment of, 170-171. 

prognosis in, 168-169. 

promotive treatment of, 175. 

removal of placenta at fifth and 
sixth months in, 180. 

method of removing retained se- 
cundines in, 178-179. 

retention of secundines in, 165. 

retroversion as cause of, 161. 

when to remove secundines in, 
178-179. 

secundines retained and second- 
ary hemorrhage after, 183. 

symptoms of, 164. 

syphilis as a cause of, 161, 186. 

vaginal tampon in, 175-176. 

treatment of, 170. 

treatment of excessive hemor- 
rhage in, 183. 

treatment of retroversion of 
uterus in, 174. 



731 



732 



Index. 



Abortion, treatment of septic infec- 
tion from retained secundines in, 
183-184. 

expulsion of one foetus in twin 
pregnancy in, 168, 177. 

use of volsella in treating, 181. 

uterine congestion as cause of, 163. 
Acephalic foetuses, 206. 
Acetabulum, 2. 
After-pains, 658. 

efficient cause of, 659. 

treatment of, 659. 
Ahlfeld: cystic placentae, 195. 
Albuminuria as a cause of abortion, 
161. 

of pregnancy, 230. 

causes, 230. 

symptoms, 231. 

effects, 231. 

prognosis, 232. 

eclampsia, 232. 

conclusions, 233. 

treatment, 234. 

in relation to paralysis, 240. 
Allantois, Development of, 68. 

as a source of nutriment, 68. 

composition of, 68. 

arteries of, 69. 

veins of, 69. 

union of, with chorion, 69. 
Aly : changing cranial positions, 414. 
Ames : frequency of uterine lacera- 
tion, 552. 
Amnii, Hydrops, 75. 
Amnion, Development of, 76. 

formation of, 67. 
Amniotic cavity, Formation of, 67. 

folds, 67. 
Amniotic fluid, 67-75. 

fluid, Anomalies of, 200. 

fluid, Deficiency of, 199, 200. 
Anaemia, 228. 
Anchylosis of sacro-coccygeal joint, 

9. 
Anencephalic foetus, 205. 
Anesthesia, Obstetrical, 348, 383. 

surgical, 384. 
Anesthetics in normal labor, 348. 

in abortion, 180. 

in midwifery, 383. 



Anesthetics, Eules for administering,, 
387. 
special indications for, 389. 
Angles of uterus, 35. 
Anidic foetuses, 206. 
Animation, Suspended, 585. 
morbid anatomy, 586. 
diagnosis and prognosis, 587. 
treatment, 587. 

Sylvester's method, 587. 
Hall's method, 588. 
Schroeder's method, 588. 
Schultze's method, 588. 
Howard's method, 589. 
Pacini's method, 590. 
comparative value of methods,, 
590. 
Anomalies of amniotic fluid, 200. 
Anorexia, 219. 
Antisepsis, 712, 726. 
during labor, 728. 
in puerperal infections, 729. 
Apoplexy of placenta, 196. 

in eclampsia, 297. 
Arbor vita? of uterine cervix, 41. 
Area germinativa : how formed, 65. 
pellucida, Formation of, 65. 
vasculosa, 65. 
Areola surrounding nipple, 56. 

changes in, during pregnancy, 98. 
discoloration of, during pregnancy, 

117. 
secondary, Of Montgomery, 98, 99. 
Armamentarium, Physician's, 338. 
Arm, Dorsal displacement of, 514. 
Arms, Development of, 77. 
Articulation, Ilio-sacral, 5, 7. 
lumbo-sacral, 5. 
pubic, 4, 7. 
sacro-vertebral, 5. 
sacro-coccygeal, 5, 8. 
Articulations of sacrum, 5, 7. 
pelvic, 7. 

pelvic, Movements at, 332. 
Ascites and vesical distension, Intra- 
uterine, 512. 
Ashwell : ovarian tumors complicat- 
ing delivery, 476. 
Asphyxia neonatorum, 585. 
morbid anatomy, 586. 



Index. 



733 



Asphyxia neonatorum, diagnosis and 
prognosis,. 587. 
treatment, 587. 

Sylvester's method, 587. 
Hall's method, 588. 
Schrceder's method, 588. 
Schultze's method, 588. 
Howard's method, 589. 
Pacini's method, 590. 
comparative value of methods, 
590. 
Atlodymes, 207. 
Atresia of uterine os, 468. 
Atrophy of placenta, 193-4. 
Attendance, Physician's, during first 

stage, 345. 
Attitude of foetus, 85. 
Augnathus, 207. 
Auricular surface of innominate 

bone, 3. 
Auscultation in diagnosis of preg- 
nancy, 111. 
diagnosis of presentation and po- 
sition by, 121. 
in diagnosis of twin pregnancy, 122. 
Autosites, 205. 

Auvard : mortality from uterine rup- 
ture, 555. 
Avicenna : puerperal fever, 708. 
Axis of parturient canal, 16-17. 
of pelvic brim, 16. 
of pelvic canal, 17. 
of pelvic outlet, 17. 

Baehr : belladonna in eclampsia, 302. 

belladonna in puerperal fever, 714. 
Bailly : pathology of eclampsia, 294. 

albuminuria, 232. 
Ballottement in pregnancy, 111. 
Bamberger : albuminuria, 232. 
Bandl, Ring of, 553. 

uterine rupture, 553. 
Bar, Paul: antisepsis, 721. 
Barker, Fordyce : frequency of albu- 
minuria, 230. 

induced labor in albuminuria, 237. 

metastatic labor-pains, 316. 

phlegmasia alba dolens, 678. 

septic infection from lacerated 
perineum, 362. 



Barker, Fordyce: puerperal fever, 

719, 723. 

Barnes, Fancourt : vascular tension 

as indicative of threatened 

eclampsia, 231. 

sphygmographic tracings, 650-652. 

Barnes, Robert : puerperal fever, 708. 

method with placenta preevia, 

521,522,527. 
uterine inversion, Reduction of, 584. 
perchloride of iron in post-partum 

hemorrhage, 575. 
form of foetal head after delivery, 

84. 
version in premature labor for 

pelvic deformity, 493. 
mortality of placenta preevia, 520. 
version in deformed pelvis, 496. 
Bartholin, Glands of, 25. 
Basiotribe, Tarnier's, 628. 
Battledore placenta, 74. 
Baudelocque : mechanism of labor, 
401. 
brow presentation, 426. 
Baudelocque's cepahalotribe, 627. 
Beau : lumbar pains during labor, 

316. 
Bed, Patient's, in labor, 345. 
Beumer : Caesarean section, 640. 
Binder, The, 379. 
Birth, Dry, 326. 

Bladder, Irritation of, during preg- 
nancy, 250. 
disturbance of, during pregnancy, 

100. 
intra-uterine distension of, 512. 
a full, in placenta previa, 528. 
Blastodermic membrane, 64. 

vesicle, Formation of, 64. 
Blechmann, M. J. : sore nipples, 691. 
Bloff : pathology of eclampsia, 294. 
Blood changes in connection with 
insanity of pregnancy, 283. 
in pregnancy, 100-101. 
changes, post-partum. 654. 
renovation of, in placenta, 79. 
hyperinosis of, during puerpe- 

rium, 654. 
circulation of, in foetus, 79. 
Blot : puerperal pulse, 652. 



734 



Index. 



Blot : tumefaction of anterior lip of 
uterus, 469. 
pathology of eclampsia, 294. 
frequency of albuminuria, 230. 
Blundell: remarks on approaching 
the patient, 339. 
version, 450. 
plural pregnancy, 501. 
long forceps, 466. 
Blunt hook, 621. 
and crotchet, 625. 
use of, in abortion, 182. 
Taylor's, 621. 
Boivin : presentations, 402. 
Bones, Moulding of cranial, 7-8. 
pelvic, Difference between male 
and female, 18-19. 
Bossi: Crede's method of placental 
delivery with respect to post- 
partum hemorrhage, 569. 
Bouillard, M. : phlegmasia alba do- 
lens, 676. 
Bourgeois: syphilis, 272. 

pneumonia during pregnancy, 267. 
Bowels during pregnancy, 248-249. 

during puerperium, 671. 
Bradley, M. M. : pulse indicative of 
threatened hemorrhage, 566, 653. 
Brain, Development of foetal, 78. 
Braim : pathology of eclampsia, 294. 
friction of fundus uteri, 371. 
hyperemesis, 219. 
uterine rheumatism, 275. 
Breasts, Changes in, in pregnancy, 
107. 
inflammation of, 692. 
etiology and symptomalogy, 693. 
pathology, 698. 
treatment, 700. 
permanent changes in. caused 

by pregnancy, 103. 
management of, in non-nursing 
women, 665. 
Breech presentation, Diagnosis of, 

118-119. 
Bregma, 83. 
Breisky : alcohol in puerperal fever, 

718. 
Brim of the pelvis, 12. 
of pelvis, Axis of, 16. 



Brim of the pelvis, Diameters of, 13. 

of pelvis, Plane of, 15. 
Broad ligaments, Changes in, during 

pregnancy, 91-99. 
Brow presentation, 425. 
Budin : ligature of the cord, 366. 
figures representing twin preg- 
nancy, 502, etc. 
Bulbi vestibuli, 26. 
Bunsen : method with placenta prse- 

via, 522. 
Burns : frequency of uterine rupture, 

552. 
Burrows : insanity of pregnancy, 285. 

Cesarean section, The operation, 
634. 

the parietal incision, 635. 

opening of the uterus, 635. 

extraction of foetus, 635. 

removal of secundines, 638. 

closure of uterine wound, 639-641. 

after-care of the patient, 642. 

post-mortem, 642. 

after uterine rupture, 560. 
Cesarean and Porro operations com- 
pared, 647. 
Calcareous deposit on uterine sur- 
face of placenta, 195. 
Calculus, Vesical, 472. 
Calipers, 486. 

Canal, Cervical, of uterus, 37. 
of Nuck, 36. 

parturient, Axis of, 17. 

pelvic, Axis of, 17. 

termination of spinal, 6-11. 
Caput succedaneum, 415. 
Cardiac diseases, 263. 
Caruncul?e myrtiformes, 24. 
Carus, Curve of, 17. 
Catheter, 260. 

soft rubber, 622. 

mode of holding, 623. 

use of, in labor, 349. 

use of, after labor, 670. 
Catheterism,621. 

mode of performing, 622. 
Cauda equina, 6-11. 
Cauliflower excrescence, 470. 
Cavity of uterus, 37. 



Index. 



735 



Cazeaux : craniotomy and Cesarean 
section, 470. 
mechanism of dilatation, 324. 
no lesions in eclampsia, 294. 
sore nipples, 690. 
uterine rheumatism, 275-277. 
diagnosis of transverse presenta- 
tion, 443. 
Cebocephalic foetuses, 206. 
Cephalalgia before eclampsia, 295. 
Cephalomelus, 207. 
Cephalopagi, 206. 
Cephalotribe, The, 627. 
Baudelocque's, 627. 
Lusk's, 628. 
Cervico-bregmatic diameter of fcetal 

head, 84. 
Cervix of uterus, 35. 
arbor vitae of, 41. 
complete obliteration of canal of, 

468. 
carcinoma of, a as cause of rigid 

os, 469. 
changes in, during pregnancy, 110. 
changes in, in extra-uterine preg- 
nancy, 146, 147. 
glands of, 41. 
mucous membrane of, 41. 
penniform rugae of, 41. 
changes of position of, in preg- 
nancy, 93, 96. 
rigidity of, 463. 
symptoms, 464. 
treatment, 465. 
shortening of, during pregnancy, 

94, 95. 
change in size and texture of, dur- 
ing pregnancy, 93. 
Chamberlen : invention of the for- 
ceps, 620. 
Champneys, F. H. : relative value of 
methods in asphyxia neonato- 
rum, 590. 
Chapman : Chamberlen's forceps, 

605. 
Charpentier : pathology of eclampsia, 
294. 
etiology of eclampsia, 293. 
insanity of pregnancy, 279. 
monstrosities, 204. 



Charpentier : presentations in pelvic 
deformity, 487. 

uterine rupture, 553. 

syphilis during pregnancy, 270. 

thrombus of the vagina and vulva, 
470. 

de Ribes : traction force in head- 
last cases, 497. 

recognition of transverse presenta- 
tion, 443. 

uterine rheumatism, 275. 
Chaussier: intra -uterine fracture, 
203. 

diagnosis of intra-uterine hydro- 
cephalus, 509. 
Chetelain : pneumonia during preg- 
nancy, 267. 
Child, Washing and dressing of, 673. 
Child-bed fever, 708. 

history, 708. 

etiology, 709. 

frequency, 711. 

symptoms, 711. 

duration, 712. 

diagnosis, 712. 

prognosis, 712. 

prophylaxis, 712. 

post-mortem appearances, 714. 

treatment, 714. 

conclusions, 719. 

curette, 718. 

mortality, 708. 
Chloroform in labor, 383, 348. 

rules for administering, 387. 

special indications for, 389. 
Chorda dorsalis, 66. 
Chorea during pregnancy, 238. 
Chorion, Changes in, at formation of 
the placenta, 69. 

degenerative changes in, 190. 

formation of, 65, 68. 

hydatidiform mole of, 189. 

cause of hydatidiform degenera- 
tion of, 190. 

hydatidiform mole of, Treatment 
of, 192-3. 

diagnosis of hydatidiform mole of, 
192. 

prognosis of hydatidiform mole of, 
192. 



736 



Index. 



Chorion, as a nutritive source, 68. 

pathological changes in, during 
pregnancy, 189. 

formation of permanent, 69. 

rupture of, during pregnancy, 67. 

villi of, 68. 

changes in villi of, 71. 
Churchill : mortality in prolapse of 
the funis, 540. 

transverse presentation, 442. 

prognosis of transverse presenta- 
tion, 446. 

frequency of uterine laceration, 
552. 
Circulation of blood in foetus, 79. 
Clark, Campbell : temperature dur- 
ing insanity, 281. 
Celosomic foetuses, 205. 
Clitoris, Component parts of, 21. 

corpus of, 21. 

crura of, 21. 

development of, 78. 

dimensions of, 21. 

erection of, 26. 

glans of, 21. 

suspensory ligament of, 21. 

mucous membrane covering glans 
of, 21. 

nerve supply of, 21. 

prepuce of, 21. 

situation of, 20-21. 

vascular supply of, 21. 
Coccygeus muscle, 33. 
Coccyx, 6, 8, 14. 

movements of, 6. 

ossification of separate segments 
of, 9. 

styloid processes of, 6. 
Cohen : method with placenta prse- 

via, 522. 
Cohnstein : abortion from injury 

during pregnancy, 246. 
Coiling of the cord, 201. 
Collins : pathology of eclampsia, 294. 
Colostrum, 98, 664, 674. 
Columnar rugarum of vagina, 29. 
Commissures, Cranial, 82. 

anterior and posterior, of vulva, 
20. 
Comstock's forceps, 608. 



Comstock, T. Griswold : puerperal 

fever, 708. 
Conception, 60. 

Configuration of head in vertex pres- 
entation, 415. 
of head in face presentation, 421. 
of head in pelvic presentation, 435, 
495. 
Confinement, Prediction of date of, 

131-132. 
Constipation during pregnancy, 247. 
Constriction, Uterine tetanoid, 467. 
Constrictor vaginas muscle, 33. 
Contagion of puerperal fever, 709. 
Contraction, "Cannon-ball," 564. 
Contractions of the vagina during 
labor, 314. 
of the uterus, 311. 
Convulsions, Puerperal, 291. 
frequency, 291. 
etiology, 291. 

pathological anatomy, 294. 
effect on pregnancy, 295. 
prodromata, 295. 
seizure, 296. 
diagnosis, 298. 

occurrence and mortality, 298. 
treatment, 299. 
Cord, umbilical, Arrest of circulation 
in r 81. 
formation of, 74. 
non-ligation of, 365. 
points for ligature of, 364. 
early and late ligature of, 365. 
pathology of, 200. 
knots, 200. 
torsion, 200. 
coiling, 201. 
hernia, 201. 
cysts, 201. 
prolapse; 539. 
frequency, 540. 
prognosis, 540. 
causes, 541. 

signs of funis presentation, 541. 
has pulsation ceased, 542. 
prevention of, 542. 
reposition of, 543. 
protection of, 545. 
version, 546. 



Index. 



737 



Cord, Treatment of, 365, 673. 
Cordiform uterus, 47. 
Cornua of uterus, 35. 
Corpus of the clitoris, 21. 

reticule, 67. 

luteum, 58. 
the true and the false, 59. 
of menstruation, 58, 59. 
of pregnancy, 59. 
Cotyloid Cavity, 2. 
Cough during pregnancy, 254. 
Cramps during pregnancy, 244. 
Cranial bones, Moulding of, 78. 
Cranioclast, The, 626. 

Simpson's, 627. 
Craniotomy forceps, Thomas's, 625. 

use of, 626. 
Craniotomy, 624. 

sphere of, 624. 

frequency of, 624. 
Cranium, Anatomy of foetal, 82. 

diameters of foetal, 84. 

form of, in vertex presentation, 415. 

form of, in face presentation, 421. 

form of, in head-last cases, 495. 
Crawford, A. K. : sphygmographic 

tracings, 651, 652. 
Crede : Cesarean section, 640. 

placental delivery, 368. 

placenta prsevia, 520. 
Crede's method of placental delivery 
in its relation to post-partum 
hemorrhage, 569. 
Crest of ilium, 3. 

Crippen, H. H. : insanity of preg- 
nancy, 278. 
Crista? of vagina, 29. 
Crotchet, The, 625. 

blunt hook and, 625. 
Crura of the clitoris, 21. 
Cul de sac, Anterior and posterior, of 
vagina, 27. 

of Douglas, 36. 
Curette, in abortion, 183. 

Leavitt's, 179. 

in puerperal fever, 718. 
Curve of Carus, 17. 
Custis, J. B. G. : mastitis, 693. 
Cyclocephalic foetuses, 206. 
Cystocele, 471. 

(47) 



Cysts of the cord, 201. 
in placenta, 195. 
of ovary complicating delivery, 475. 

Dake, "William C. : mastitis, 693. 
Danforth, L. L. : antiseptic mid- 
wifery, 721. 
phlegmasia alba dolens, 675. 
Date of confinement, Prediction of, 

131-132. 
Davis, David : phlegmasia alba 

dolens, 676. 
Death from anesthetics in labor, 387. 
sudden, during labor and puerpe- 

rium, 686. 
foetal, Signs of, during labor, 116. 
foetal, Diagnosis of, in pregnancy, 
116. 
Decapitating hook. Mode of using, 

630. 
Decapitation, 629. 
with the e'craseur, 631. 
delivery of head after, 632. 
Decidua, Pathological changes in, 
causing abortion, 185, 186. 
in extra-uterine pregnancy, 146. 
placental, 70. 
reflexa, 69. 
formation of, 70. 

changes in, during pregnancy, 
70. 
rupture of, during pregnancy, 67. 
serotina, 69, 70. 
vera, or decidua uterina, 69. 
changes in, during pregnancy, 
70. 
Deformities of the pelvis, 478. 
large pelvis, 478. 
symmetrically contracted pelvis, 

478. 
flattened pelvis, 478. 
flattened, generally-contracted pel- 
vis, 480. 
irregular rachitic and malacosteon 

pelvis, 480. 
oblique oval pelvis, 481. 
flattening of sacrum, 482. 
exaggerated sacral curve, 482. 
funnel-shaped pelvis, 482. 
infantile type of pelvis, 482. 



738 



Index. 



Deformities of the pelvis, deformities 
from spinal curvature, 482. 

anchylotic, transversely-contract- 
ed, 483. 

spondilolisthetic pelvis, 483. 

osteo-sarcoma and exostosis, 483. 

other osseous tumors and projec- 
tions, 483. 

absence of the symphysis, 484. 

causes, 485. 

diagnosis, 485. 

influence of, on uterus during preg- 
nancy, 487. 

influence of, on foetal presenta- 
tion, 487. 

influence of, on labor-pains, 488. 

effect of pressure on soft pelvic 
tissues, 489. 

effect of pressure on child's head, 
489. 

prognosis, 489. 

induction of abortion in extreme 
deformity, 490. 

induction of premature labor in 
deformed pelvis, 490. 

a substitute for premature deliv- 
ery, 493. 

when is interference during labor 
advisable, 494. 

cases wherein delivery of living 
child at term through the natu- 
ral passages is impossible, 494. 

traction force applied after version, 
with results, 497. 

forceps and version compared, 497. 

cases wherein a full-term living 
child cannot be born, but deliv- 
ery through the natural pas- 
sage is advisable, 496. 
Degeneration of placenta, 194. 
Denman : puerperal fever, 723. 
DePaul : pathology of eclampsia, 294. 

frequency of transverse presenta- 
tion, 442. 

pelvimetry, 486. 
Deradelphe, 206. 
Derodymes, 207. 
Development of uterus, 44. 
Deventer: method with placenta 
prsevia, 522. 



Devilliers: pathology of eclampsia, 

294. 
Dewees : metastatic labor-pains, 316. 
rupture of the membranes as pre- 
ventive of post-partum hemor- 
rhage, 570. 
passing the hand through the pla- 
centa, in version, in placenta 
prsevia, 531. 
Diameters of pelves, 14. 
of foetal head, 84. 

of uterus, at different months of 
gestation, 91. 
Diaphragm, 67. 

Diarrhoea during pregnancy, 249. 
Diathesis, Hemorrhagic, as a cause 
of post-partum hemorrhage, 564. 
Diday: syphilis, 272. 
Diet of pregnancy, 213. 
milk, in albuminuria, 234. 
to prevent the necessity for prema- 
ture labor in deformed pelvis, 
493. 
during puerperium, 671. 
in puerperal fever, 717. 
Digestive disorders during preg- 
nancy, 102. 
during spurious pregnancy, 139. 
Dilatation of the os, Mechanism of, 
323. 
artificial, of os uteri, 591. 
Dimensions of pelvis, 13. 
cephalic, Eelative value of differ- 
ent modes of reducing, 628. 
of foetal head, 84. 
of uterus at different months, 91. 
Discus proligerus, 52. 
Diseases of the foetus, 203. 
and accidents of pregnancy, 212. 
derangements of the digestive 
system, 215. 
nausea and vomiting, 215. 

hyperemesis, 218. 
other gastric disorders, 219. 
ptyalism, 225. 
pruritus, 226. 
face-ache, 227. 
cephalalgia, 227. 
insomnia, 228. 
anaemia, 228. 



Index. 



739 



Diseases and accidents of pregnancy, 
albuminuria, 230. 

causes, 230. 

symptoms, 231. 

effects, 231. 

prognosis, 232. 

conclusions, 233. 

treatment, 234. 
milk diet, 234. 
therapeutics, 235. 
induced labor for, 236. 
chorea, 238. 
paralysis, 240. 
syncope, 241. 
painful mammae, 241. 
pain in the side, 242. 
leucorrhcea, 242. 
odontalgia, 243. 
cramps, 244. 

traumatic complications, 244. 
constipation, 247. 
diarrhoea, 249. 
vesical irritation, 250. 
cough, 254. 
dyspnoea, 255. 
hemorrhoids, 255. 
displacements of the uterus, 257. 

ante versions and anteflexions, 
257. 

retroversion, 258. 

retroflexion, 258. 
treatment, 259. 

prolapse, 262. 
cardiac diseases, 263. 
eruptive fevers, 264. 

measles, 264. 

variola, 265. 

scarlatina, 265. 
continued fevers, 265. 

typhoid, 265. 

malarial, 266. 
pneumonia, 266. 
phthisis, 268. 
erysipelas, 269. 
syphilis, 269. 
uterine rheumatism, 276. 

influence on pregnancy, 276. 

influence on labor, 277. 

influence on the puerperal 
functions, 277. 



Diseases and accidents of pregnancy, 
uterine rheumatism, causes, 277. 
prognosis, 277. 
treatment, 277. 
insanity of pregnancy, 278. 
insanity during the period of 

pregnancy, 280. 
insanity due to lactation, 282. 
etiology, 282. 
hereditary, 282. 
number of pregnancies, 283. 
age, 283. 

qualitative changes in the 
blood, 283. 
diagnosis. 284. 
prognosis, 285. 
treatment, 286. 
eclampsia, 291. 
frequency, 291. 
etiology, 291. 

pathological anatomy, 294. 
effect on pregnancy, 295. 
prodromata, 295. 
the seizure, 296. 
diagnosis, 298. 

occurrence and mortality, 298. 
treatment, 299. 
preventive, 299. 
curative, 301. 
therapeutics, 301. 
Displacements of the gravid uterus, 
257. 
anteversions and anteflexions, 257. 
retroversion, 257. 
retroflexion, 257. 
Doleris : puerperal fever, 723. 
Dorsal plates, 65. 
Double uterus, 47. 
Douche, Cervical, for induction of 

labor, 592. 
Douglas's pouch, 26. 

spontaneous expulsion, 447. 
Dress, Patient's, in labor, 345. 
Dressing forceps in return of the 

cord after prolapse, 545. 
Dubois : etiology of eclampsia, 292. 
non-nursing women, 664. 
method with placenta praevia, 522. 
presentations, 402. 
thrombus of vagina and vulva, 470. 



740 



Index. 



Ducts, Galactophorous, of mammary 
glands, 55. 
galactophorous, Muscular fibers in, 
55. 
Ductus arteriosus, 81. 

venosus, 79. 
Duer: post-mortem Cesarean sec- 
tion, 642. 
Duncan, Matthews : power of uterine 
contractions, 313. 
endometritis during pregnancy, 

185. 
clinical definition of fourchette, 

363. 
uterine inversion may begin at the 

cervix, 582. 
induced labor in deformed pelvis, 

491. 
movements of pelvic bones, 332. 
rotten perineum, 363. 
placental extrusion, 334. 
Barnes's method with placenta 

prgevia, 527. 
puerperal mortality, 649. 
uterine stem worn during preg- 
nancy, 245. 
Duplex uterus, 47. 
Duration of pregnancy, 127. 

of pregnancy, Comparative,127-128. 
of extra-uterine pregnancy, 147- 
148. 
Duveney, Glands of, 25. 
Dyspnoea during pregnancy, 255. 

Eclampsia, 291. 

frequency, 251. 

etiology, 291. 

pathological anatomy, 294. 

effect on pregnancy, 295. 

prodromata, 295. 

seizure, 296. 

diagnosis, 296. 

occurrence and mortality, 298. 

treatment, 299. 

and albuminuria, 232. 
Ecraseur, the, Decapitation with, 631. 
Ectoderm : structures which it en- 
ters into formation of, 65-66. 

formation of, 65. 
Ectopage, 206. 



Ectromeles, 205. 

Edis : prevention of weak labor, 457. 
Edocephalic foetuses, 206. 
Electricity for nausea and vomiting 
of pregnancy, 217. 

in treatment of extra-uterine preg- 
nancy, 152. 

in post-partum hemorrhage, 576. 

in induced labor, 594. 
Embolism, Thrombosis and, 686. 
Embryo : definition of term, 159. 

development of, 76. 
Embryonic spot, Formation of, 65. 
Embryotomy, 629. 

Emmet : contagion of puerperal 
fever, 709. 

subinvolution uteri, 563. 
Emotions, Violent, as a cause of sud- 
den death, 688. 
Endochorion, 69. 

Endometritis during pregnancy, 185. 
Engelmann: treatment of prolapse 

of the cord, 546. 
Entoderm, Formation of, 65. 

structures which it enters into 
formation of, 66. 
Epignathus, 207. ' 
Episiotomy, 361. 

Erysipelas during pregnancy, 269. 
Esquirol : insanity of pregnancy, 

280, 285. 
Ether in labor, 348, 383. 

rules for administering, 387. 
Ethnocephalic foetuses, 206. 
Eustachian valve, 79. 
Evisceration, 632. 

Evolution, Spontaneous, in trans- 
verse presentation, 446. 
Examinations, Vaginal, during la- 
bor, 339. 

external, during labor, 341. 
Excission of labia minora, 22. 
Excretions, The, 660. 
Exencephalic foetuses, 205. 
Exochorion, 69. 

Expulsion, Spontaneous, in trans- 
verse presentation, 446. 
Extra-peritoneal pregnancy, 144. 
Extra-uterine pregnancy, 140. 

attachment of placenta in, 142. 



Index. 



741 



Extra-uterine pregnancy, Diagnosis 
of, 149-150. 

causes of, 140. 

duration of, 147-148. 

decidua in, 146. 

labor-pains in, 149. 

symptoms of, 147. 

termination of, 147, etc. 

symptoms of rupture of mem- 
branes in, 148. 

treatment after rupture of sac, 153. 

uterine changes in, 146. 

treatment of, 151. 

treatment of, gestation prolonged 
after foetal death, 155-156. 
Eyes, Development of, 77. 

Face presentations, 417. 

character of labor in, 417. 

causes, 417. 

diagnosis, 118. 

relative frequency of positions in, 
418. 

mechanism of first position of, 418. 

form of the cranium in, 421. 

prognosis, 421. 

mechanism of second position, 422. 

mechanism of third and fourth po- 
sitions, 422. 

treatment, 422. 

conversion into vertex presenta- 
tion, 422. 

management when the face does 
not enter the brim, 424. 

persistent mento-posterior posi- 
tion, 425. 
Fallopian tubes, Changes in, during 
pregnancy, 99. 

fimbriated extremity of, 48. 

functions of, 48. 

measurements of, 48. 

mobility of, 49. 

mucous membrane lining, 49. 

ostium uterinum of, 49. 

position of, during gestation, 91. 

situation of, in broad ligament, 49. 

structure of walls of, 49. 

manner in which they receive the 
ovule, 58. 

action of, in propelling ovum, 60. 



False ovarian pregnancy, 141. 
Farrington : comparison of remedies 
in insanity, 290. 

hyoscyamus in acute mania, 287. 
Fasbender's method of perineal pro- 
tection, 358. 
Fecundation, 60. 

point at which, takes place, 60. 

process of, 61, 62. 
Feet, Bringing down the, 598. 
Fernald : insanity of pregnancy, 279. 
Fevers, Continued, 265. 

eruptive, during pregnancy, 264. 
Fever, Puerperal, 708. 

history, 708. 

mortality, 708, 721. 

etiology, 709. 

frequency, 711. 

symptoms, 711. 

duration, 712. 

diagnosis, 712. 

prognosis, 712. 

prophylaxis, 712. 

post-mortem appearances, 714. 

treatment, 714. 

curette in, 718. 

conclusions, 719. 
Fillet, Turning by, 603. 
Fimbriated extremity of Fallopian 

tube, 48. 
Floor of pelvis, 10. 
Fluid, amniotic, Anomalies of, 200. 

seminal, Secretion of, 60. 
Foetus, Abnormalities of, 509-514. 

effect of anaesthetics on, 386. 

attitude of, 85. 

extraction of, in Cesarean section, 
635. 

circulation of blood in, 79. 

death of, 203. 

death and retention of, 207. 

diagnosis of death of, 116. 

definition of term, 159. 

development of, in different 
months of pregnancy, 78. 

conditions of, favoring expulsion, 
403. 

diseases of, 203. 

expulsion of one, in twin preg- 
nancy, 168. 



742 



Index. 



Foetus, Heart-sounds of, in preg- 
nancy, 111-112. 

heart of, in diagnosis of sex, 
124-125. 

large, 513. 

membranes covering, in extra- 
uterine pregnancy, 142. 

maceration of, 209. 

monstrosities of, 204. 

mortality of, in pelvic presenta- 
tion, 427. 

movements of, 78. 

movements of, in diagnosis of preg- 
nancy, 107. 

position of, 85, 88. 

presentation of, 85, 86. 

diagnosis of presentation and posi- 
tion of, 117-118. 

putrefaction of, 208. 

effect of uterine contractions on, 
314. 

effect of violence on, 203. 
Folds, Amniotic, 67. 

mesenteric, 66. 
Follicles, Graafian, of ovary, 50. 
Fontanelles, 83. 

posterior, Situation of, during 
labor, 83. 
Footling presentation, 433. 
Foramen ovale, Closure of, 81. 

obturator, 2. 

sacral, 5, 6. 
Foramina, Sacro-sciatic, 10. 
Forceps, The, 605. 

Chamberlen's, 605. 

the short, 605. 

the long, 606. 

features of the, 606. 

cephalic curve of, 606. 

pelvic curve of, 607. 

axis-traction, 607, 608, 609. 

Comstock's, 608. 

Kearny's, 607. 

Leavitt's, 608, 609. 

Knox's, 606. 

Tarnier's, 609. 

Stone's, 606. 

designations of blades of, 610. 

action of, 610. 

modes of applying, 611. 



Forceps, Pelvic application of, 611. 
cephalic application of, 611. 
conditions calling for, 611. 
preliminaries of application of, 611. 
application of, 612. 
traction on, 613. 
removal of, 614. 

in occipito-posterior positions, 615. 
imperfect seizure with, 614. 
as applied in cephalic mode, 615. 
rotation of head with, 616. 
above the brim, 495. 
in uterine inertia, 459. 
in face presentation, 617. 
in placenta prsevia, 528. 
and version compared, 497. 
craniotomy, The, 626. 
Thomas's, 625. 
Fossa navicularis, Location of, 24. 
Foster, E. N. : cephalic version be- 
fore labor in pelvic presentation, 
435. 
Fourchette, Destruction of, in labor, 

24, 363. 
Fournier : syphilis, 271. 
Fox, Tilbury : phlegmasia alba do- 
lens, 678. 
Fractures, Intra-uterine, 203. 
Frrenum, Destruction of, in labor, 

24. 
Fritsch : puerperal mortality, 721. 
Frommel : operations during preg- 
nancy, 246. 
Funis, Formation of, 74. 
size of, etc., 75. 
prolapse of, 539. 
frequency, 540. 
prognosis, 540. 
causes, 541. 

signs of funis presentation, 541. 
has pulsation ceased, 542. 
prevention of, 542. 
reposition, 543. 
protection, 545. 
version, 546. 
early and late ligature of, 365. 
non-ligation of, 365. 
points for ligature of, 364. 
treatment of, 365. 
pathology of, 200. 



Index. 



743 



Funis, Pathology of, knots, 200. 
torsion, 200. 
coiling, 201. 
hernia, 201. 
cysts, 201. 

Galactophorous, or lactiferous, 

ducts, 55. 
Ganlard : phthisis during pregnancy, 

268. 
Gardner, A. K. : operative interfer- 
ence, 466. 
Garrigues, Henry J. : antiseptic 

midwifery, 724. 
Garrigues : rescue of child after 

profound asphyxia, 587. 
Gassner : maternal loss in weight as 

the result of labor, 334. 
Gastric derangements during preg- 
nancy, 102. 
Gastro- hysterotomy, 634. 
Gastromelus, 207. 

Gauthier : uterine rheumatism, 275. 
Gay : uterine tetanoid constriction, 

467. 
Generative organs, Female, 20. 
external, 20. 
internal, 20. 
Germinal area, Formation of, 65. 
Germinal vesicle, Disappearance of, 

63. 
Germinative spot of ovule, 52. 
Germinative vesicle of ovule, 52. 
Glands of Bartholin, 25. 
of cervix uteri, 41. 
of Duverney, 25. 
secretory, of labia minora or 

nymphae, 22. 
mammary, 54. 
of Naboth, 41. 

mucous, of the vestibule, their aid 
in locating meatus urethrae, 25. 
mucous, of the vulva, 24. 
of the uterus, 41. 
sebaceous, of vulva, 24. 
vulvo-vaginal, 25. 
of the clitoris, 21. 
Goitre, 275. 

Grisolle : pneumonia during preg- 
nancy, 267. 



Gonorrhoea as a cause of puerperal 

fever, 710. 
Gooch : acute mania, 285. 
Goodell : perineal protection, 358. 
traction force to deliver after-com- 
ing head, 434. 
version in deformed pelvis, 496. 
Goubeyre : albuminuria, 232. 
Graafian follicles of ovary, 50. 
development of, 57. 
discharge of ovum from, 57. 
discus proligerus of, 52. 
external membrane of, 51-52. 
time of laceration of, 58. 
macula or stigma folliculi of, 57. 
membrana granulosa of, 52. 
number of, contained in ovary, 51. 
cause of its rupture, 57. 
structure of, 51-52. 
Gravitation, theory of presentations, 

88. 
Greenhalgh : method with placenta 

previa, 521-522. 
Grisolle : phthisis during pregnancy, 

268. 
Gross : compression of the breast, 

703. 
Guerin : syphilis, 271. 
Guernsey, H. N. : belladonna in 

eclampsia, 302. 
Guernsey, William J. : therapeutics 

of mastitis, 704. 
Guernsey's uterine elevator as a 
means of reducing uterine in- 
version, 260, 585. 
Guillemeau : method with placenta 
praevia, 521, 530. 

Hair, Development of foetal, 78. 

Hale, E. M. : actsea rac. in melan- 
cholia, 286. 
bromide of potassium in mania, 
287. 

Hall, Marshall : etiology of eclamp- 
sia, 292. 

Hall's method with asphyxia neona- 
torum, 588. 

Hand disinfection, 727. 

Hanwell: insanity of pregnancy, 
280. 



744 



Index. 



Hardy : pathology of eclampsia, 294. 
Harris, Robert P. : obstetric lapa- 
rotomy statistics, 647. 
frequency of uterine laceration, 

552. 
recovery after uterine rupture, 
559. 
Hart : protection of perineum, 357. 
Harvey: intra-uterine injections, 

721. 
Head, after-coming, Difficult extrac- 
tion of, 434. 
fcetal, Anatomy of, 82. 
delivery of, after decapitation, 632. 
development of, 77. 
diameters of, 84. 
form of, in vertex presentation, 

415. 
form of, in face presentation, 421. 
form of, in pelvic presentation, 

435. 
form of, in head-last cases, 495. 
moulding of, 82, 83, 498. 
movements of, in labor, 404, 419. 
extraction of, in pelvic presenta- 
tion, 440. 
effect of pressure on, 489. 
presentations, 86. 

presentations of, Cause of prepon- 
derance of, 86, 87. 
relative size of male and female, 

85. 
foetal, Rotation of, in pelvic cavity, 
331. 
Heart, Changes in, during preg- 
nancy, 101, 102. 
hypertrophy of, during pregnancy, 

651. 
diseases of the, 263, 688. 
foetal, period when first heard, 112. 
fcetal, frequency of, 112. . 

fcetal, in twin pregnancy, 122. 
foetal, in diagnosis of presentation 

and position, 121. 
foetal, in diagnosis of sex, 124, 125. 
Hebra : puerperal fever, 722. 
Hegar's signs of pregnancy, 109, 110. 
Helm : pathology of eclampsia, 294. 
Hemimeles, 205. 
Hemipage, 206. 



Hemorrhage as a symptom of abor- 
tion, 164. 
control of, by hot water in abor- 
tion, 181. 
control of, by hot water, after la- 
bor, 574. 
control of, by tampon, 175, 176, 524. 
accidental, 546. 
character, 546. 
relation of foetus and placenta to 

uterus, 546. 
causes, 547. 
varieties, 547. 

symptoms of external hemor- 
rhage, 547. 
symptoms of concealed hemor- 
rhage, 548. 
differential diagnosis, 548. 
prognosis, 549. 
treatment, 549. 
post-partum, 562. 
causes, 562. 

premonitory symptoms, 565. 
general symptoms, 566. 
secondary hemorrhage, 567. 
prognosis, 568. 
treatment, 569. 
hemorrhage of the first degree, 

571. 
second degree, 572. 
third degree, 573. 
use of hot water, 574. 
use of styptics, 575. 
compression of aorta. 575. 
electricity, 576. 
transfusion, 576. 
concealed hemorrhage, 566, 

577. 
conclusions, 577. 
Crede's method of placental de- 
livery in relation to, 569. 
after placenta previa, 518. 
complicated by uterine polypi, 475. 
unavoidable, 515. 
causes, 516. 
symptoms, 517. 
diagnosis, 518. 
prognosis, 520. 
treatment, 521. 
Hemorrhoids during pregnancy, 255. 



Index. 



745 



Hernia of the cord, 201. 

Hervieux : thrombus of vulva and 

vagina, 471. 
Heschl: uterine involution, 657. 
Heterodelph, 207. 
Heterodyne, 207. 
Heterolicus, 207. 
Heteropage, 207. 
Hewitt : hydatidiform degeneration 

of chorion, 190. 
Hicks : uterus convulsed in eclamp- 
sia, 296. 
vaginal tampon in placenta pre- 
via, 524. 
method of version, 597. 
version in placenta previa, 532. 
method with placenta prsevia, 522. 
Hicks, Braxton : method with pla- 
centa prsevia reduces mortality, 
520. 
Higbee, C. G. : phlegmasia alba do- 
lens, 675. 
Hippocrates : puerperal fever, 708. 
Hirst : obliquely-contracted pelvis, 

481. 
Hodge : etiology of eclampsia, 292. 
Hofmeir : albuminuria, 232. 
frequency of albuminuria, 230. 
induced labor in albuminuria, 236. 
Hohl: pulse in labor, 321. 

method of perineal protection, 357. 
Hollow of sacrum, 6. 
Holmes, Oliver Wendell: puerperal 

fever, 721. 
Hook, Blunt, 621. 
Taylor's blunt, 621. 
blunt, and crotchet, 625. 
decapitating, Mode of using, 630. 
placenta, 182. 
placenta, Leavitt's, 182. 
Horn of uterus, Pregnancy in, 145. 
Hosmer : uterine tetanoid constric- 
tion, 467. 
Hospitals, Lying-in, of the future, 714. 
Howard's method in asphyxia neon- 
atorum, 589. 
Hoyne, T. S. : lunar influence on par- 
turition, 335. 
therapeutics of syphilis, 274. 
Huckle-bone, 6. 



Hughes, Richard: belladonna in 
puerperal fever, 714. 

phosphorus in pneumonia, 268. 
Hydatidiform mole of chorion, 189. 

degeneration of chorion, Cause of, 
190-192. 

mole of chorion, Diagnosis of, 192. 
expulsion of, 192. 
prognosis of, 192. 
treatment of, 192-193. 
Hydremia during pregnancy, 229. 
Hydramnios, Definition of, 197. 

diagnosis of, 198. 

termination of, 198. 

uterine inertia in, 198. 

uterine involution after, 199. 

shape of abdomen in, 197-198. 

effect of, on labor, 199. 

mother's heart in, 199. 

symptoms of, 197. 

prognosis in, 199. 

treatment of, 199. 
Hydrocephalus, Intra-uterine, 509. 

diagnosis, 509. 

presentation, 510. 

treatment, 510. 
Hydrops amnii, 75. 
Hydrorrhea gravidarum, Diagnosis 
of, 188. 

abortion caused by, 187. 

treatment of, 188. 
Hydrothorax, Intra-uterine, 512. 
Hymen, Anatomy of, 23-24. 

anomalies in form of, 24. 

rupture of, 23-24. 

unyielding, 473. 
Hyperemesis, 218. 
Hyperencephalic foetuses, 205. 
Hyperinosis, 677. 

during puerperality, 654. 
Hypertrophy of placenta, 193. 
Hypodermic injections, 621. 

syringe, Use of, 621. 
Hypognathus, 207. 
Hysteria in pregnancy, 239. 

Iliac muscles, 53. 
Iliodelphe, 206. 
Ilio-lumbar ligament, 11. 
Ilio-pectineal line, 3-4. 



746 



Index. 



Ilio-sacral ligaments, 9-10. 
Ilio-sacral synchondrosis, 5-7, 

ligaments of, 9-10. 
Ilium, 2-3. 
Ilium, Crest of, 3. 

Illegitimacy in relation to insanity, 
284. 

sex, 126. 
Impregnation, 60, 61, 62. 
Incarceration of anterior lip of os in 

labor, 349. 
Induced labor, 591. 

prognosis, 591. 

methods, 591. 

for albuminuria, 236. 

in deformed pelvis, 490. 
Inertia, Uterine, 455. 

forceps in, 459. 

as a complication of third stage, 
460. 
Infection, autogenetic, 726. 

puerperal, Antiseptic treatment 
of, 729. 

prevention of, 725. 

from retained placenta, 183-184. 
Inflammation of placenta, 196. 
Iniencephalic foetuses, 205. 
Injections into sac to destroy foetus 
in extra-uterine pregnancy, 152. 

intra-uterine, for induction of la- 
bor, 592. 

of hot water for hemorrhage, 181, 
574. 
Injuries during pregnancy, 244. 
Innominate bone, 1. 

auricular surface of, 3. 

component parts of, 1. 

ossification of component parts of ,1. 
Inopexia,.677. 
Insanity of pregnancy, 278. 

lactation, 282. 

etiology, 282. 

heredity, 282. 

number of pregnancies, 283. 

age, 283. 

qualitative blood changes, 283. 

diagnosis, 284. 

prognosis, 285. 

treatment, 286. 
Insomnia, 228. 



Inspection to diagnose pregnancy, 

106. 
Interference, Indications for, in la- 
bor, 348. 
Interstitial pregnancy, 142. 

duration of, 148. 
Intestines, Formation of, 66. 

disturbances of, during pregnancy, 
100. 
Intra-pelvic muscles, 53. 
Intra-uterine amputations, 203 

death, 207. 

diseases, 203. 

fractures, 203. 
Inversion, Acute, of the uterus, 581. 

symptoms, 582. 

treatment, 583. 
Involution of the uterus, 656. 
Ischio-cavernosus muscle, 33. 

coccygeus muscle, 33. 
Ischium, 2-3. 

inclined planes of, 18. 

spines of, 4. 

tuberosities of, 4. 

Jacqttemire : no lesions in eclampsia, 

294. 
Jahr : cuprum in mania, 287. 
Janiceps, 206. 
Jenner : vaccination, 721. 
Joint : lumbo-sacral, 5. 

ilio-sacral, 5, 7. 

pubic, 4, 7. 

sacro-coccygeal, 5, 8. 

sacro-vertebral, 5. 
Joints, Movements at pelvic, 332. 
Jolly : cause of uterine rupture, 554. 

frequency of uterine laceration, 
552. 

symptoms of uterine rupture, 555. 
Jousset : phosphorus in pneumonia, 
268. 

Kehrer : foetal heart, 314. 

Keith, Thomas: uterine rupture with 
hydrocephalus, 509. 

Kelley, Howard A. : hand disinfec- 
tion, 727. 

King: results of induced labor in 
placenta praevia, 523. 



Index. 



747 



Kiwisch : no lesions in eclampsia, 294. 
induced labor in pelvic deformity, 

492. 
puerperal fever, 723. 
Knee-chest position for reduction of 

retroflexion during pregnancy, 

260. 
Knot, The square, 365. 
Knots of the cord, 200. 
Knox's short forceps, 606. 
Koch : puerperal fever, 723. 
Kristeller: method with placenta 

praevia, 522. 

Labia majora, 20. 
minora, 20. 

attachment of, to clitoris, 22. 

excision of, 22. 

formation of, 21. 

secretory glands of, 22. 

location of, 21. 

formation of prepuce from, for 
glans of clitoris, 22. 
anterior and posterior, of uterine 

cervix, 35. 
Labor, Abdominal aid during, 314. 
causes and character of, 307. 
character of, in face presentation, 

417. 
clinical course and phenomena of, 

318. 
prediction of date of, 131. 
sudden death during, 686. 
signs of foetal death during, 116. 
dry, 326. 

duration of, 334. 
pains in extra-uterine pregnancy, 

149. 
movements of head in, 404. 
the hour of, 335. 
effect of hydramnios on, 199. 
when is interference during, 

advisable in pelvic deformity, 

494. 
lunar influence on, 335. 
management of normal, 357. 
missed, 157. 
the mechanism of, 390. 
mechanism of, in first position of 

vertex, 403. 



Labor, mechanism of second position 

of vertex, 409. 
mechanism of occipito- posterior 

positions in, 409. 
mechanism of face presentations, 

418. 
mechanism of pelvic presentations, 

439. 
the pains of, 315. 
effect of pains of, on mother and 

foetus, 314. 
influence of pelvic contraction on, 

488. 
movements of pelvic articulations 

in, 332. 
modes of promoting, in placenta 

praevia, 523. 
in plural pregnancy, 503. 
expelling powers of, 311. 
premature, Cause of, 159-160. 

definition of, 159. 

induction of, 591, 236, 490. 

when to induce, in deformed pel- 
vis, 492. 

a substitute for, 493. 

prognosis, 591. 

methods, 591. 

induction of, for albuminuria, 
236. 

induction of, in deformed pelvis, 
490. 
proof of former, 117. 
quickening, as means of predict- 
ing date of, 132. 
stages of, 318. 
first stage, 318. 

mechanism of dilatation, 323, 327. 

action of the bag of waters, 324. 

rupture of membranes, 320. 

preliminary arrangements, 337. 

prompt response to calls, 337. 

armamentarium, 338. 

how to approach the patient, 338. 

examinations, 339. 

external examination, 341. 

has it begun, 342. 

false pains, 342. 

patient's bed and dress, 345. 

position of patient, 345. 

physician's attendance, 345. 



748 



Index. 



Labor, first stage, bearing efforts, 346- 
347. 
treatment of membranes, 346. 
second, or propulsive, stage of, 329, 
347. 
use of anesthetics in, 348. 
indications for interference in, 

348. 
use of catheter during, 349. 
incarceration of anterior lip of 

os during, 349. 
prevention of vulvar laceration 

during, 349. 
frequency of vulvar laceration 
during, 362. 
precipitate, 454. 

obstructed by pelvic and abdomi- 
nal tumors, 474-475. 
obstructed by rigid perineum, 477. 

weak, 455. 
third stage of, 333, 367. 

separation and extrusion of pla- 
centa in, 334. 
delivery of placenta in, 368. 
general therapeutics of, 380. 
phenomena succeeding, 649. 
changes caused by, 117. 
loss of maternal weight as the re- 
sult of, 334. 
inner surface of uterus after, 658. 
Laceration of the cervix, 560. 
of the uterus, 552. 
of the vagina, 561. 
vulvar, Prevention of, 349. 
vulvar, Extent of, 363. 
immediate repair of, 371. 
Lachapelle : intra-uterine hydro- 
cephalus, 509. 
mortality in prolapse of the funis, 

540. 
rigid os, 464. 
sudden death, 687. 
Lactation, 664, 681. 
abundant, 689. 
insanity of, 282. 
unsatisfactory, 688. 
Lacteal secretion, The, 664. 
Lactiferous ducts, 55. 
Lange: cedematous infiltration of 
placenta, 195. 



Lanugo, Development of, 78. 

disappearance of, from face, 78. 
Laparo-elytrotomy, 647. 
Laparotomy, Obstetric, 634. 

in extra-uterine pregnancy, 153. 
Larcher: maternal heart during 

pregnancy, 651. 
Leavitt's curette, 179. 

forceps, 608, 609. 

placenta hook, 182. 
Lebart : phthisis during pregnancy, 

269. 
Lebas : uterine sutures, 639. 
Lee, Henry : phlegmasia alba dolens, 

677. 
Lehmann : frequency of uterine lace- 
ration, 552. 
Leidesdorff: insanity of pregnancy, 

280, 285. 
Leishman: spontaneous evolution, 
447. 

mechanism of os dilatation, 323. 

pelvic deformity, 481. 

uterine inertia, 455. 

turning after uterine rupture, 556. 

version in placenta prsevia, 530. 
Leopold: Cesarean section, 640. 
Leroux : method with placenta prse- 

via, 521, 525. 
Leucorrhoea during pregnancy, 242. 
Levator ani muscle, Attachments 

of, 31, 33. 
Lever : albuminuria, 230. 

pathology of eclampsia, 294. 
Levret : intra-uterine injections, 721. 
Ligament, Suspensory, of clitoris, 21. 

ilio-lumbar, 11. 

obturator, 11, 12. 
Ligaments of ovaries, 49. 

of pelvis, 9. 

of ilio-sacral synchondroses, 9, 10. 

of lumbo-sacral joint, 10, 11. 

of pubic joint, 9. 

of sacro-coccygeal joint, 11. 

sacro-sciatic, 10. 

of the uterus, 35. 

broad, Changes in, during preg- 
nancy, 99. 

round, Changes in, during preg- 
nancy, 99. 



Index. 



749 



Ligature of the cord, 364, 365, 673. 

early and late. 350. 
Line, Ilio-pectineal, 3, 4. 
Liquor amnii, 67. 
formation of, 75. 
escape of, during pregnancy, 67. 
evacuation of, in management of 
unavoidable hemorrhage, 524. 
Litzman : frequency of albuminuria, 
230. 
split pelvis, 484. 

induced labor in deformed pelvis, 
491. 
Lochia, The, 661. 

Lomer : changing cranial positions, 
414. 
experience with placenta prrevia, 
520. 
Lorain : sphygmographic tracings, 

650, 651. 
Ludlam, R. : treatment of albumi- 
nuria, 235. 
treatment of chorea of pregnancy, 

238. 
treatment of eclampsia, 301. 
Lumbo-sacral joint, 5, 10, 11. 
Luroth : uterine rheumatism, 276. 
Lusk : decidual changes causing 
abortion, 186-1S7. 
forceps applied to the breech, 618. 
cephalotribe of, 628. 
causes of labor, 307. 
pelvic deformity, 499. 
mechanism of os dilatation, 325. 
protection of perineum, 357. 
perineal softening, 359. 
removal of retained placenta, 461. 
occipito-posterior positions, 615. 
uterine rupture, 553. 
recovery after uterine rupture, 
557. 
Lymphatics of ovary, 53. 
of placenta, 71. 
of umbilical cord, 75. 
of uterus, 44. 
of vagina, 30. 

Macan : milk fever, 664. 
Macdonald : insanity of pregnancy, 

280. 



Maceration of foetus, 209. 
Mackenzie : phlegmasia alba dolens, 

677. 
Macula of Graafian follicle, 57. 
Macuhe of pregnancy, 103. 
Mahomed : pulse during pregnancy, 

651. 
Malarial fever during pregnancy, 

266. 
Mammse, Anatomy of, 54. 

anomalies in form, number and 

position of, 54. 
changes in, during pregnancy, 54, 

97, 117. 
ducts of, 55. 
inflammation of, 692. 

etiology and symptomatology. 

693. 
pathology, 698. 
treatment, 700. 
inspection of, in diagnosis of preg- 
nancy, 107. 
lobes and Lobules of, 54. 
management of, in non-nursing 

women, 665. 
nerve supply of, 56. 
painful, during pregnancy, 241. 
sinus of ducts of, 55. 
vascular supply of, 56. 
Mania, Puerperal, 278. 
Marce : insanity of pregnancy, 280. 
Martin : alcohol in puerperal fever, 
718. 
cause of cord torsion, 200. 
Massmann : frequency of prolapse of 

the funis, 540. 
Mastitis puerperalis, 692. 
etiology and symptomatology, 693. 
pathology, 698. 
treatment. 700. 
Mattel : lumbar pains during labor, 

316. 
Maudsley : borderland of insanity, 

280. 
Maurieeau : phlegmasia alba dolens, 

675. 
McClintock : intra-uterine death, 
208. 
sudden death, 687. 
prognosis in hydramnios, 199. 



750 



Index. 



McClintock : rupture of the mem- 
branes as preventive of postpar- 
tum hemorrhage, 570. 
pathology of eclampsia, 294. 
puerperal mortality, 649. 
reduction of uterine inversion, 
584. 
Meadows : dilatation of the os, 327. 
sudden death, 686. 
symptoms of acute inversion of 
the uterus, 582. 
Measles during pregnancy, 264. 
Meatus urethrse, Location of, 622. 

opening of, in vestibule, 23. 
Mechanism of labor, 390. 
first position of vertex, 403. 
second position of vertex, 409. 
occipito-posterior positions, 409. 
first position of face, 418. 
brow presentation, 418. 
first and second positions of breech 

presentation, 429. 
third and fourth positions of the 
breech, 431. 
Medullary substance of ovary, 50. 

tube, 66. 
Meigs : labor-pains, 315. 
placenta prsevia, 521. 
version in placenta prsevia, 532. 
puerperal fever, 708. 
Membranes, Treatment of, in labor, 
346. 
rupture of, 329. 
Meissner : uterine rheumatism, 277. 
Melcker: quantity of foetal blood, 

366. 
Melomelus, 207. 

Membrana granulosa of Graafian 
follicle, 52. 
pupillaris, Development of, 78. 
Membrane, blastodermic, Formation 
of, 64. 
obturator, 11-12. 
Membranes, Rupture of, in induced 
labor, 591. 
arrangement of, in plural preg- 
nancy, 501. 
action of, in os dilatation, 320. 
treatment of, in labor, 346. 
rupture of, 329. 



Menstruation, Corpus luteum of, 58- 
59. 
during pregnancy, 105-106. 
Mercier : pathology of eclampsia, 294. 
Merriman: induced labor in de- 
formed pelvis, 491. 
reduction of uterine inversion, 
584. 
Mesenteric folds, Formation of, 66. 
Mesoderm, Formation of, 65. 
division of, 65. 

formation of intestine from, 66. 
formation of mesenteric folds 
from, 66. 
Metopagi, 206. 

Meyer, Leopold : conclusions con- 
cerning albuminuria, 233. 
variola during pregnancy, 265. 
Midwifery, antiseptic, 721. 
Migration of ovum, 59-60. 
Milk, 664. 

. diet in albuminuria, 234. 
deficient, 688. 
fever, 664. 
leg, 675. 
etiology, 675. 
symptoms, 680. 
diagnosis, 682. 
prognosis, 683. 
treatment, 683. 
metastasis of, 679. 
Miodymes, 207. 

Miscarriage, definition of term, 159. 
frequency of, 159-160. 
causes of, 161, 162, 163. 
use of anesthetics in, 180, 185, 186. 
use of curette in, 183, 187. 
placenta forceps and blunt hook 

in, 182. 
methods of emptying uterus in, 

176. 
incomplete, 165. 

diagnosis of, 166. 
neglected cases of, 182-183. 
treatment of, 170. 
when to remove secundines in, 

178-179. 
expulsion of one foetus in twin 
pregnancy, 168, 177. 
Missed labor, 157. 



Index. 



751 



Mitchell, J. Nicholas : mastitis, 693. 
Molas : pathology of eclampsia, 294. 
Moles, uterine, 209. 
of abortion, 209. 
carneous, 209. 
hydatidiform, 209. 
Moleschott: alcohol in puerperal 

fever, 718. 
Monocephalic foetuses, 206. 
Monomphalic foetuses, 206. 
Monosomic foetuses, 207. 
Monsters, composite, 206. 

simple, 205. 
Monstrosities, 204. 
Mons veneris, 20. 
Montgomery, Secondary areola of, 

99. 
Morning sickness, as a sign of preg- 
nancy, 102, 106. 
Morsus diaboli, 48. 
Mortality in eclampsia, 298. 
infantile, in pelvic presentation, 

427. 
puerperal, 723-724. 
Moulding of cranial bones, 78. 

of foetal head, 82. 
Movements of coccyx during labor, 

14. 
Movements of foetus, 78. 
Muciparous glands of vestibule, 23. 
Mucous membrane of uterus, 40, 41. 
of vestibule, 23. 
of uterus, Reaction of, 41. 
of vagina, 29. 
glands of the vulva, 24. 
Miiller, P. : induction of labor in 

retroversion of uterus, 261. 
Multipara, Uterus of, at term, 657. 
Mummification of the foetus, 208. 
Munde : clinical observation of uter- 
ine action, 327. 
vaginal tampon, 525. 
Miinster : Cesarean section, 640. 
Muscles, Coccygeus, 33. 

of galactophorous ducts, 55. 
iliac and psoas, 53. 
intra-pelvic, 53. 
ischio-cavernosus, 33. 
ischio-coccygeus, 33. 
obturator internus, 54. 



Muscles of perineum, 30, 31, 33. 

transverse perinaei, 33. 

pyriformis, 53. 

of uterine walls, 38. 

constrictor vaginae, 33. 

levator ani, 31-33. 
Muscular fibers in nipples, 56. 
Myopes, 206. 
Myxoma of placenta, 195. 

Naboth, Glands of, 41. 

ovula of, 42. 
Naegele : mechanism of labor, 401. 
Nails, Development of, 78. 
Nausea and vomiting of pregnancy, 

215. 
Navel, Dressing for the, 674. 

condition of, after birth, 674. 
Navicular fossa, 24. 
Neck of uterus, 35. 

development of, 77. 
Nerves, Changes in, during preg- 
nancy, 102. 

of clitoris, 21. 

of mammary gland, 56. 

of ovary, 53. 

of placenta, 71. 

sacral, Pressure on, during preg- 
nancy, 100. 

of umbilical cord, 75. 

of vagina, 30. 

of uterus, 43. 

vaginal and uterine plexuses, 43. 
Neucourt : uterine rheumatism, 276. 
Neuralgia, as a cause of abortion, 

162. 
Nipple, Anatomy of, 55. 

areola surrounding, 56. 

changes in, during pregnancy, 98. 

muscular fibers in, 56. 

openings of lactiferous ducts in, 
55. 

sebaceous follicles in, 56. 

depressed, 689. 

sore, 690. 
Noose, Running, for use in version. 

602. 
Notches, Sacro-sciatic, 10. 
Notencephalic foetuses, 205. 
Nourishment of ovum, 67. 



752 



Index. 



Nuck, Canal of, 36. 
Nymph?e, location of, 21. 

Obermann : Cesarean section, 640. 
Obturator membrane, or ligament, 
11-12. 

internus muscle. 54. 
Octocephalic foetuses, 206. 
Odontalgia during pregnancy, 243. 
(Edema during pregnancy, 229, 231. 
(Edema lacteum, 575. 
Olshausen: changing cranial posi- 
tions, 415. 

perineal protection, 357. 
Omphalosites, 206. 
Oophorohysterectomy, 644. 
Operation, Cesarean, 634. 

Porro's, 644. 

with cephalotribe, 627. 

with cranioclast, 626. 

with basiotribe, 628. 

by embryotomy, 629. 

for decapitation, 629. 

by evisceration, 632. 

of obstetric laparotomy, 634. 

of laparo-elytrotomy, 647. 

of gastro hysterotomy, 634. 

of craniotomy, 624. 

of catheterism, 622. 

with blunt hook, 621. 

with vectis, 620. 

with forceps, 611. 

comparison of Cesarean and 
Porro's, 647. 

of symphyseotomy, 648. 
Operations; Obstetric, 591. 

during pregnancy, 246. 
Opocephalic foetuses, 206. 
Opodymes, 207. 

Organs of generation in females, 20. 
Orifice of vagina, Location of, 23. 
Os basilare, 4. 
Os coccyx, 6. 

movements of, 6-8. 

styloid processes of, 6. 
Os ilium, 2-3. 

crest of, 3. 

anterior and posterior spines of, 3. 
Os innominatum, 1. 

auricular surface of, 3. 



Os innominatum, Ossification of ili- 
um, ischium and pubis to form,l. 
Os ischium, 2-3. 

spines of, 4. 
Os pubis, 2, 4. 

arch of, 4, 7. 
Os sacrum, 4. 

articulations of, 5, 7. 

promontory of, 5. 

hollow of, 6. 

mechanical relations of, 8. 
Ossification of innominata bones, 1. 

of segments of coccyx, 9. 
Os uteri, Atresia of, 468. 

artificial dilatation of, 591. 

mechanism of dilatation of, 323. 

dilatile and contractile powers of, 
327. 

in pregnancy, 96-97. 

rigid, 463. 

symptoms, 464. 

treatment, 465. 
Ould, Sir Fielding: mechanism of 

labor, 401. 
Ovarian pregnancy, 140. 

pregnancy, Duration of, 148. 
Ovaries, Changes in, during preg- 
nancy, 99. 

peritoneal coat of, 49. 

cortical layer of, 50. 

function of, 49. 

Graafian follicles of, 50. 

ligaments of, 49. 

lymphatics of, 53. 

measurements of, 49. 

medullary substance of, 50. 

changes in, at puberty, 57. 

situation of, in broad ligaments, 
49. 

situation of, during gestation, 91. 

structure of, 50. 

tunica albuginea of, 50. 
Ovary, Action of muscle fibers in 
rupture of Graafian follicle, 58. 

nerves of, 52-53. 

vessels of, 52, 53. 
Oviducts, 48. 
Ovisacs of ovary, 50. 
Ovula of Naboth, 42. 
Ovular decidua, 69. 



Index. 



753 



Ovules, Anatomy of, 52. 

development of, 50-51. 

germinative spot of, 52. 

germinative vesicle of, 52. 

vitelline membrane of, 52. 

vitellus, or yolk, of, 52. 

zona pellucida of, 52. 
Ovum, Blighted, 209. 

changes in, after fecundation, 63. 

disappearance of germinal vesi- 
cle, 63. 

discharge of, from Graafian follicle, 
57. 

premature expulsion of, 159. 

formation of blastodermic mem- 
brane of, 64. 

migration of, to uterus, 59, 60. 

source of nourishment of, 67, 68. 

passage of, into tube, 58. 

penetration of, by spermatozoa, 
61. 

segmentation of yolk of, 63, 64. 

Pacini's method in asphyxia neona- 
torum, 590. 
Pains, labor, False, 342. 
causes of, 343. 
diagnosis of, 343. 
treatment of. 344. 
Pajot : head flexion, 405. 

diagnosis of position in transverse 

presentation, 445. 
delivery through greatly-con- 
tracted pelves, 628. 
"intercostal gridiron," 443. 
law of foetal accommodation, 88. 
Palmre plicate, 41. 
Palmer : insanity of pregnancy, 280, 

285. 
Palpation as a means of diagnosis of 
pregnancy, 108. 
as a means of diagnosis of presen- 
tation, 119-120. 
Pampiniform venous plexus, 43. 
Papillae of the vaginal walls, 29. 
Paracephalic foetuses. 206. 
Paralysis during pregnancy, 240. 
Pare, Ambrose : version in placenta 
praevia, 530. 
internal podalic version, 600. 
(48) 



Parry, John S. : changing positions, 

414. 
craniotomy in pelvic deformity, 

500. 
Parturient canal, Axis of, 16, 17. 
Parturition, Clinical course and phe- 
nomena of, 318. 
stages of, 318. 
first stage, 318. 

mechanism of dilatation, 323. 

action of the bag of waters, 324. 
second, or propulsive, stage of, 329, 

347. 
dilatation of os, 327. 
rupture of membranes in, 329. 
movements of pelvic articulations, 

332. 
separation and extrusion of pla- 
centa, 334. 
maternal loss in weight as the 

result of, 334. 
third stage of, 333, 367. 

duration of, 334. 
the hour of, 335. 

how to approach the patient, 338. 
examinations in, 339. 
external examination in, 341. 
has labor begun, 342. 
false pains, 342. 
patient's bed and dress, 345. 
position of patient, 345. 
physician's attendance during 

first stage of, 345. 
bearing efforts during, 346, 347. 
treatment of membranes during, 

346. 
use of anesthetics in, 348. 
indications for interference in, 348. 
use of catheter during, 349. 
incarceration of anterior lip of os 

during, 349. 
prevention of vulvar laceration 

during, 349. 
frequency of vulvar laceration, 

362. 
management of the third stage of, 

461. 
dry, 326. 
character of, in face presentation, 

417. 



754 



Index. 



Parturition, Induced, 591. 

prognosis, 591. 

methods, 591. 

for albuminuria, 236. 

for deformed pelvis, 490. 
lunar influence on, 335. 
management of normal, 337. 
mechanism of, in first position of 

vertex, 404. 

of second position of vertex in, 
409. 
! of occipito-posterior positions 
in, 409. 

of face presentation, 418. 

of pelvic presentation, 429. 
movements of head in, 404. 

of pelvic bones in, 332. 
obstructed by pelvic and ab- 
dominal tumors, 474, 475. 
obstructed by a rigid perineum, 

477. 
the pains of, 315. 
expelling powers of, 311. 
precipitate, 454. 
in pleural pregnancy, 503. 
influence of pelvic contraction on, 

488. 
preliminary arrangements for, 337. 
prompt response to calls, 337. 
armamentarium for, 337. 
premature, Definition of, 159. 
premature, Induction of, 591, 236, 

490. 
general therapeutics of, 380. 
weak, 455. 
Parvin : etiology of eclampsia, 293. 
protection of perineum, 355. 
abdominal section after uterine 

rupture, 557. 
Pasteur : puerperal fever, 723. 
Paul : intra-uterine death, 203. 
Peck, Geo. B. : pneumonia during 

pregnancy, 267. 
frequency of eclampsia, 291. 
mortality of eclampsia, 298. 
frequency of transverse presenta- 
tion, 442. 
management of the breasts of non- 
nursing women, 666. 
Pellucid area, Formation of, 65. 



Pelvic presentation, 427. 
frequency of, 427. 
prognosis, 427. 

causes of infant mortality in, 427. 
etiology of, 428. 
diagnosis of, 429. 

mechanism of first and second po- 
sitions of the breech, 429. 
mechanism of third and fourth po- 
sitions of the breech, 431. 
footling presentation, 433. 
breathing space for the foetus in, 

433. 
difficult extraction of after-coming 

head, 434. 
configuration of the head in, 435. 
management of, 435. 
cephalic version before labor in, 

435. 
cephalic version during labor in, 

440. 
extraction of head in, 440. 
Pelvimetry, 485. 
Pelvis, Anatomy of, 1. 
articulations of, 7. 
canal of, Axis of, 17. 
bones of, 1. 

bones of, male and female, 18-19. 
superior or false, Boundary of, 12. 
inferior or true, Boundary of, 12. 
brim of the, 12. 
brim of, Plane of, 15. 
component parts of, 1. 
definition of, 1. 
deformity of, 478. 

large, 478. 

symmetrically contracted, 478. 

flattened, 478. 

generally contracted, 480. 

irregular rachitic and malacos- 
teon, 480. 

oblique oval, 481. 

flattening of sacrum, 482. 

exaggerated sacral curve, 482. 

funnel-shaped, 482. 

infantile type of, 482. 

deformities from spinal curva- 
ture, 482. 

anchylotic, transversely - con- 
tracted, 483. 



Index. 



755 



Pelvis, deformity of, spondilolis- 

thetic, 483. 

osteo-sarcoma and exostosis, 483. 

other osseous tumors and projec- 
tions, 483. 

absence of the symphysis, 484. 

causes, 485. 

diagnosis, 485. 

influence of, on uterus during 
pregnancy, 487. 

influence of, on total presenta- 
tion, 487. 

influence of, on labor-pains, 488. 

effect of pressure on soft pelvic 
tissues, 489. 

effect of pressure on child's head, 
489. 

prognosis, 489. 

induction of abortion in extreme, 
490. 

induction of premature labor in, 
490. 

a substitute for premature de- 
livery in, 393. 

when is interference during 
labor advisable, 494. 

cases wherein delivery of living 
child at full term through the 
natural passages is possible, 
494. 

traction force applied after ver- 
sion, with results, 497. 

forceps and version compared, 
497. 

cases wherein a full-term living 
child cannot be born, but deliv- 
ery through the natural pas- 
sages is advisable, 499. 

cases wherein extraction 
through the natural passages 
appears to be impossible, 499. 
diameters of, 14. 
shortest diameter of, 14. 
longest diameter of, 14. 
dimensions of, 13. 

variation of, 13. 
floor of, 10. 

female, Form of, 18-19. 
inclinations of, 14-15. 
plane of superior strait of, 15. 



Pelvis, plane of inferior strait of, 15. 

ligaments of, 9. 

masculine form of, 18-19. 

differences in male and female, 
18-19. 

outlet of, Plane of, 15. 

planes of, 15-16. 

structure of, 12. 

superior strait of, 12. 
Penniform ruga of cervix uteri, 41. 
Percussion as a means of diagnosis 

in pregnancy, 111. 
Perforator, The, 625. 

Thomas's, 624. 

Blot's, 624. 
Perineorrhaphy, Immediate, 710. 
Perineum, Anatomy of, 30. 

body of, 30. 

elasticity of, 33. 

form of, 33. 

functions of, 33. 

measurements of, 30, 33. 

muscles of, 30, 31. 

Hohl's method of protection, 357. 

Fasbender's method of protection, 
358. 

means of softening, as a protection 
against rupture, 358. 

Goodeli's method of perineal pro- 
tection, 358. 

immediate repair of, 371, 710. 

rigidity of, obstructing delivery, 
477. 

rotten, 363. 

extent of rupture of, 363. 

prevention of laceration of, 349. 

frequency of laceration of, 362. 

manual protection of, 355. 

protection of, during forceps de- 
livery, 360. 

body, Situation of, 33. 

structure of, 30. 

support of, 355, 356. 

surfaces of, 30. 
Peritoneal covering of uterus, 37, 38. 
Phillips, L. A. : cramps during preg- 
nancy, 244. 
Phlebitis, Crural, 677. 
Phlegmasia alba dolens, 675. 

etiology, 675. 



756 



Index. 



Phlegmasia alba dolens, symptoms, 
680. 

diagnosis, 682. 

prognosis, 683. 

treatment, 683. 
Phocomeles, 205. 
Phthisis during pregnancy, 268. 
Pigmentation during pregnancy, 103. 

of placenta, 195. 
Piles during pregnancy, 255. 
Pilliet, Alex. : pathology of eclamp- 
sia, 294. 
Placenta, 70. 

abnormalities in form of, 74. 

amorphous calcareous deposits on, 
195. 

apoplexy and inflammation of, 
196. 

atrophy of, 193. 

attachment of, in extra-uterine 
pregnancy, 142. 

battledore, 74. 

changes in, before separation at 
term, 74. 

composition of, 73. 

cysts in, 195. 

decidua, 70. 

degeneration of, 194. 

normal and abnormal mode of ex- 
trusion of, 334. 

mixed method of delivery of, 368. 

delivery of, by expression, 368. 

Crede's method of delivering, 368. 

rotation of, in delivery, 370. 

development of, 78. 

forceps, to evacuate uterus in 
abortion, 182. 

form of, 73. 

formation of, 70. 

functions of, 73. 

hook, Leavitt's, 182. 

hypertrophy of, 193. 

infection from retained, in abor- 
tion, 183-184. 

oedematous infiltration of, 195. 

inflammation of, Cause and dan- 
gers of, 197. 

insertio valamentosa, 74. 

inversion of, by traction on the 
cord, 361. 



Placenta, lobes of, 73. 
lymphatics and nerves of, 71. 
marginal presentation of, 372. 
myxoma of, 195. 
new formation of, 194. 
pigmentary deposits in, 195. 
prsevia, 515. 

varieties, 516. 

frequency, 516. 

causes of hemorrhage, 516. 

symptoms, 517. 

diagnosis, 518. 

prognosis, 520. 

treatment, 521. 
removal in fragments, in abortion, 

180. 
retained, 579. 

treatment, 579. 
retention of, by irregular uterine 

contraction, 460. 
retention of, from uterine inertia, 

461. 
separation and expulsion of, 334. 
partial separation of, in placenta 

prsevia, 527. 
complete separation of, in pla- 
centa prsevia, 526. 
sinuses of, 71. 
situation of, 194. 

situation of, in extra-uterine preg- 
nancy, 194. 
size of, 193-194. 
souffle of, 113. 
succenturiata, 74, 568. 
syphilis of, 196. 
circumscribed tumors of, 195. 
weight of, 73. 
Planes of the pelvis, 15, 16. 
of pelvic brim, 15. 
of pelvic outlet, 15. 
inclined, of ischium, 18. 
inclined, of pelvis, 17. 
Plates, Dorsal, 65. 

lateral or abdominal, 66. 
Playfair : treatment of hydramnios, 

199. 
induced labor in albuminuria, 237. 
the teeth during pregnancy, 244. 
mechanism of os dilatation, 325. 
treatment of inversio uteri, 583. 



INDEX. 



757 



Playfair: frequency of prolapse of 
cord, 540. 
induced labor in deformed pelvis, 

490. 
placenta prsevia, 523. 
ovarian tumor complicating labor, 

476. 
diagnosis of intra-uterine hydro- 
cephalus, 509. 
post-mortem Cesarean section, 643. 
Plexuses, Uterine and pampiniform, 

43. 
Pneumonia during pregnancy, 266. 
complicating measles during preg- 
nancy, 264. 
Podencephalic foetuses, 205. 
Poloin : uterine sutures, 639. 
Polygnathus, 207. 
Polypi, Uterine, complicating labor, 

473. 
Polypoid growths causing abortion, 

187. 
Poppel : power of uterine contrac- 
tions, 314. 
mortality of asphyxia neonatorum, 
587. 
Porak : ligation of the cord, 367. 
Porro's operation, 644. 
and Cesarean operation compared, 

647. 
operation after uterine rupture, 
560. 
Positions of the foetus, 88, 390. 
classification, 390. 
relative frequency, 39S. 
points of coincidence, 399. 
Position of foetus, Diagnosis of, 117, 
118. 
diagnosis of, by auscultation, 121. 
- heart-sounds in diagnosis of, 121, 
122. 
vaginal examination in diagnosis 

of, 118. 
conversion of occipito-posterior 

into occipito-anterior, 413. 
Scanzoni's method of changing 

cranial positions, 414. 
and presentation, Changes of, 88, 

402. 
relative frequency of face, 418. 



Position of foetus, ^Relative fre- 
quency of first, of vertex, 402. 

knee-chest, for reduction of retro- 
flexion during pregnancy, 260. 

mechanism of second, of vertex, 
409. 

mechanism of occipito-posterior, 
409. 

mechanism of first, of the face, 
418. 

mechanism of labor in first and 
second, of breech, 429. 

mechanism of labor in third and 
fourth, of the breech, 431. 

persistent mento-posterior, 425. 

of patient during labor, 345. 
Post-mortem appearances in puer- 
peral fever, 714. 

Cesarean section, 642. 

delivery through the natural pas- 
sages, 643. 
Post-partum hemorrhage, 579. 

causes, 562. 

premonitory symptoms, 565. 

general symptoms, 566. 

secondary hemorrhage, 567. 

prognosis, 568. 

treatment, 569. 
of first degree, 571. 
of second degree, 572. 
of third degree, 573. 

use of hot water, 574. 

use of styptics, 575. 

compression of the aorta, 575 

electricity, 576. 

transfusion, 576. 

concealed hemorrhage, 566, 577. 

conclusions, 577. 

foretold by the pulse, 653. 

anesthetics in relation to, 385. 

Crede's method of placental deliv- 
ery in relation to, 569. 

visits by physician, 668. 

regimen, 671. 

care of the woman, 378. 

blood changes, 654. 

retention of urine, 668. 

time for getting up, 672. 
Poullet : presentation in hydroceph- 
alus, 510. 



758 



Index. 



Powers, Expelling, of labor, 311. 
Prediction of date of confinement, 

131, 132. 
Pregnancy, 57. 
abdominal, 141. 

changes in abdomen during, 99, 117. 
form of abdomen during, 106-107. 
flattening of abdomen in, 92. 
enlargement of abdomen in, 92. 
disturbance of abdominal organs 

from pressure during, 100. 
deficiency of amniotic fluid during, 

199. 
changes in areola during, 98. 
auscultation in diagnosis of. 111. 
ballottement as a sign of, 111. 
changes in blood during, 100-101. 
changes in the maternal organism 
wrought by, 90. 
uterus, 90. 
situation, 92. 
inclination of longitudinal axis, 

93. 
cervical position, 93. 
size and texture of cervix, 93. 
vagina and vulva, 97. 
mammae, 97. 
uterine appendages, 99. 
abdomen, 99. 

neighboring organs from pres- 
sure, 100. 
blood, 100. 
miscellaneous, 102. 
permanent, 103. 
rupture of chorion and decidua 

during, 67. 
pathological changes in chorion 

during, 189. 
changes in position of cervix dur- 
ing, 93, 96. 
changes in cervix during, 110. 
corpus luteum of, 59. 
changes in decidua during, 70. 
differential diagnosis of, 113-114, 
diagnosis of, 104. 
diseases and accidents of, 212. 
derangements of the digestive 
system, 215. 

nausea and vomiting, 215. 
hyperemesis, 218. 



Pregnancy, Diseases and accidents 
of, other gastric disorders, 219. 
ptyalism, 225. 
pruritus, 226. 
face-ache, 227. 
cephalalgia, 227. 
insomnia, 228. 
anaemia, 228. 
albuminuria, 230. 

causes, 230. 

symptoms, 231. 

effects, 231. 

prognosis, 232. 

conclusions, 233. 

treatment, 234. 
milk diet, 234. 
therapeutics, 235. 
induced labor for, 236. 
chorea, 238. 
paralysis, 240. 
syncope, 241. 
painful mammae, 241. 
pain in the side, 242. 
leucorrhoea, 242. 
odontalgia, 243. 
cramps, 244. 

traumatic complications, 244. 
constipation, 247. 
diarrhoea, 249. 
vesical irritation, 250. 
cough, 254. 
dyspnoea, 255. 
hemorrhoids, 255. 
displacements of the uterus, 257. 

anteversions and anteflexions, 
257. 

retroversion, 258. 

retroflexion, 258. 
treatment, 259. 

prolapse, 262. 
cardiac diseases, 263. 
eruptive fevers, 264. 

measles, 264. 

variola, 265. 

scarlatina, 265. 
continued fevers, 265 

typhoid, 265. 

malarial, 266. 
pneumonia, 266. 
phthisis, 268. 



Index. 



759 



Pregnancy, erysipelas, 269. 
syphilis, 270. 

uterine rheumatism, 276. 
influence on pregnancy, 276. 

on labor, 277. 

on the puerperal functions, 277. 
causes, 277. 
prognosis, 277. 
treatment, 277. 
insanity of, 278. 
during the period of, 280. 
during the period beginning with 

labor and ending with the 

lochial discharge, 281. 
due to lactation, 282. 
etiology, 282. 

heredity, 282. 

number of pregnancies, 283. 

age, 283. 

qualitative changes in the 
blood, 283. 
diagnosis, 284. 
prognosis, 285. 
treatment, 286. 
eclampsia, 291. 
frequency, 291. 
etiology, 291. 

pathological anatomy, 294. 
effect on pregnancy, 295. 
prodromata, 295. 
the seizure, 296. 
diagnosis, 298. 

occurrence and mortality, 298. 
treatment, 299. 

preventive, 299. 

curative, 301. 

therapeutics, 301. 
duration of, 127. 
minimum, at which child may 

live, 130. 
comparative, 127-128. 
endometritis during, 185. 
extra-peritoneal, 144. 
extra-uterine, 140. 
abdominal, Etiology of, 141. 
attachment of placenta in, 142. 
causes of, 140. 
changes in cervix during, 146- 

147. 
decidua in, 146. 



Pregnancy, extra-uterine, duration 
of, 147-148. 
injections into sac, in treatment 

of, 152. 
labor-pains in, 149. 
diagnosis of, 149-150. 
laparotomy in treatment, 153. 
rupture of foetal coverings in, 

142. 
formation of covering mem- 
branes in, 142. 
interstitial, 142. 

duration of, 148. 
ovarian, 140. 

duration of, 148. 
false ovarian, 141. 
sub-peritoneo-pelvic, 146. 
symptoms of, 147. 
termination in, 147. 
termination and prognosis in, 

148-149. 
treatment of, 151. 
by electricity, 152. 
after rupture of sac, 153. 
advanced cases of extra-uter- 
ine foetus still living, 154. 
extra-uterine gestation, pro- 
longed after death of foetus,. 
155-156. 
tubal, 143. 
development of foetus in, 144. 
causes of, 143. 
duration of, 148. 
rupture of walls of tube in, 144. 
tubo-abdominal, 141. 
tubo-interstitial, 142. 
tubo-ovarian, 141. 
utero-tubo-abdominal, 145-146. 
diagnosis of foetal death during, 

116. 
foetal heart-sounds in diagnosis, 

111. 
foetal movements in diagnosis of,, 

107. 
nausea and vomiting of, 215. 
gastric disturbances during, 102. 
changes in heart during, 101-102. 
Hegar's sign of, 109-110. 
hydramnios during, 196-197. 
hygiene of, 212. 



760 



Index. 



Pregnancy, insanity of, 278. 
inspection in diagnosis of, 106. 
changes in mamma) caused by, 

97, 117. 
menstruation during, 105-106. 
molar, 209. 
changes in nervous system during, 

102. 
changes in nipple caused by, 98, 

117. 
operations during, 246. 
palpation as means of diagnosis 

of, 108. 
pathology of, 140. 
percussion in diagnosis of, 111. 
permanent changes caused by, 

103, 117. 
pigmentation during, 103. 

of areola during, 117. 
plural, 501. 
arrangement of membranes in, 

501. 
conditions attending intra-uter- 

ine development of, 502. 
labor in, 503. 

management of first birth in, 503. 
delay after birth of first child in, 

504. 
locked twins, 506. 
double monsters, 507. 
twin, Heart sounds in, 122. 
expulsion of one foetus in, 168. 
premature expulsion of ovum dur- 
ing, 159. 
procidentia during, 263. 
proof of former, 117. 
quickening a sign of, 106. 
relation of uterus to surrounding 

parts during, 99. 
respiratory derangements during, 

102. 
changes in senses during, 102. 
signs of, 104. 

classification, 105. 
subjective signs, 105. 

history, 105. 

menses, 105. 

morning sickness, 106. 

unreliability of subjective signs, 
106. 



Pregnancy, objective signs, 106. 

inspection, 106. 

abdomen, 106. 

foetal movements, 107. 

breasts, 107. 

vagina, 107. 

palpation : 
abdomen, 108. 
vagina, 109. 
combined touch, 111. 
ballottement, 111. 

percussion, 111. 

auscultation, 111. 
foetal heart, 112. 
uterine souffle, 113. 
positive signs of, 105. 
objective signs of, 105. 
relative signs of, 105. 
spurious, 136. 

etiology, 136. 

symptoms, 137. 

diagnosis, 138, 139. 

treatment, 139. 
influence of syphilis on, 271. 
retraction of umbilicus during, 92. 
changes in urine during, 103. 
uterine changes during, 90-91. 
fluctuation of uterus in, I'll, 
changes in uterine appendages 

during, 99. 
position of uterus during, 90-91. 
changes in uterus caused by, 117. 
size of uterus during different 

months of, 133. 
appearance of vagina during, 107. 
changes in vagina and vulva dur- 
ing, 97. 
changes in vulva caused by, 117. 
increase of weight during, 103. 
in rudimentary horn of the uterus, 

145. 
Prepuce of clitoris, 21. 
formation of, from labia minora, 

22. 
Presentations, 86. 
breathing space for the foetus in 

pelvic, 433. 
brow, 425. 
their causes, 86. 
cephalic, of foetus, 86. 



Index. 



761 



Presentations and positions, Changes 

of, 402. 
of foetus, Diagnosis of, 117-118. 
diagnosis of, by auscultation, 121. 
breech, Diagnosis of, 118-119. 
diagnosis of cephalic, 118. 

of face, 118. 
heart-sounds in diagnosis of, 121- 

122. 
diagnosis of, by palpation, 119-120. 
transverse, Diagnosis of, 119. 
vaginal examination in diagnosis 

of, 118. 
diagnosis of vertex, 118. 
face, 417. 

character of labor, 417. 

causes, 417. 

relative frequency of positions, 
418. 

mechanism of first position, 418. 

form of the cranium, 421. 

prognosis, 421. 

mechanism of second position, 
422. 

mechanism of third and fourth 
positions, 422. 

treatment, 422. 

conversion into vertex presenta- 
tion, 422. 

management when the face does 
not enter the brim, 424. 

persistent mento-posterior posi- 
tions, 425. 
footling, 433. 
head, 86. 
gravitation as a causative factor, 

88. 
head, Cause of preponderance, 86, 

87. 
pelvic, 86, 427. 

frequency, 427. 

prognosis, 427. 

causes of infant mortality, 427. 

etiology, 428. 

diagnosis, 429. 

mechanism of first and second 
positions of the breech, 429. 

mechanism of third and fourth 
positions of the breech, 431. 

footling presentation, 433. 



Presentations, Pelvic, breathing 
space for the foetus, 433. 
difficult extraction of after-com- 
ing head, 434. 
configuration of the head, 435. 
management, 435. 
cephalic version before labor, 435. 
cephalic version during labor, 440. 
extraction of head, 440. 
reflex movements of foetus a causa- 
tive factor of, 88. 
transverse, 86, 442. 
frequency, 442. 
causes, 442. 
diagnosis, 443. 
prognosis, 446. 

unaided termination, 446, 451. 
treatment, 447. 
uterine contractions as a causative 

factor in, 88. 
vertex, 401. 
relative frequency, 401. 
diagnosis of, 118. 
mechanism of labor in first posi- 
tion, 403. 
mechanism of second position, 

409. 
mechanism of occipito-posterior 

positions, 409. 
configurations of the head, 415. 
diagnosis of position, 416. 
Pressure, effect of, on soft pelvic tis- 
sues in pelvic deformity, 489. 
Primitive trace, Formation of, 65. 

chorion, 65. 
Prochownick, T. : a substitute for 

premature labor, 493. 
Procidentia during pregnancy, 263. 
Proencephalic foetuses, 205. 
Prolapse of the uterus, 262. 
Promontory of sacrum, 5. 
Pruritus, 226. 
Pryor: prevention of post-partum 

hemorrhage, 570. 
Pseudencephalic foetuses, 205. 
Pseudocyesis, 135. 
conditions of development, 135. 
etiology, 136. 
symptoms, 137. 
diagnosis, 138. 



762 



Index. 



Pseudocyesis, treatment, 139. 

Psope muscles, Action of, in labor, 

53. 
Psodymes, 207. 
Ptyalism, 225. 
Pubes, 2-4. 
articulation of, 4, 7. 
arch of, 4, 7. 
spines of, 4. 
symphysis of, 4, 7. 
Pudenda, 20. 
Puerperal diseases, 675. 
fever, 708. 

history, 708. 

etiology, 709. 

frequency, 711. 

symptoms, 711. 

duration, 712. 

diagnosis, 712. 

prognosis, 712. 

prophylaxis, 712. 

post-mortem appearances, 714. 

treatment, 714. 

conclusions, 719. 

curette in, 718. 

mortality from, 708. 
infections, antiseptic treatment of, 

729. 
mania, 278. 
mortality, 649. 
pulse, 650. 
regimen, 671. 
septicaemia, 680. 
temperature, 655. 
Puerperium, First attentions in, 378. 
attentions to women during, 667. 
physician's visits during, 668. 
retention of urine during, 668. 
use of catheter during, 670. 
diet during, 671. 
regimen during, 671. 
bowels during, 671. 
temperature of room during, 673. 
time for getting up, 672. 
hyperinosis during, 654. 
pulse during, 651. 
temperature during, 655. 
diseases during, 675. 
sudden death during, 686. 
mortality in, 723-724. 



Pulse, Arterial tension of, during 
pregnancy, 651, 652, 654. 
rapidity of, indicating threatened 

hemorrhage, 653. 
the puerperal, 650. 
during pregnancy, 650. 
during foetal expulsion, 650. 
Putrefaction of the foetus, 208. 
Puzos: method with placenta prsevia, 
522, 524. 
phlegmasia alba dolens, 676. 
Pygomelus, 207. 
Pygopagi, 206. 
Pyriformis muscles in labor, 53. 

Quickening as a sign of pregnancy, 
106. 
date of, as means of predicting 
date of labor, 132, 133. 

Rachel : death from puerperal fever, 
708. 

Ramsbotham : induced labor in de- 
formed pelvis, 491. 
no lesions in eclampsia, 294. 

Raue, C. G. : lunar influence on 
parturition, 335. 

Reamy's forceps, 607. 

Reamy : uterine tetanoid constric- 
tion, 467. 

Recolin : intra-uterine injections, 721. 

Rectocele, 472. 

Rectum, Disturbances of, during 
pregnancy, 100. 

Reed, Charles A. L. : treatment of 
uterine rupture, 555. 

Reeve, J. C. : anesthetics, 386. 

Regnauld : pathology of eclampsia, 
294. 

Renhac, Solayres de : mechanism of 
labor, 401. 

Respiration, Derangements of, dur- 
ing pregnancy, 102. 

Restitution, 406. 

Retention of secundines in abortion, 
165. 

Reuss : intra-uterine amputations, 
203. 

Rheumatism, Uterine, 275. 

Rhinocephalic foetuses, 206. 



Index. 



763 



Eibemont : ligation of the cord, 367. 
power of uterine contractions, 
314. 

Rican: pneumonia during preg- 
nancy, 267. 

Richardson, "William L. : puerperal 
mortality, 724. 

Rigaud: mortality in pelvic deform- 
ity, 489. 

Rigby : unaided termination of 
transverse presentation, 446. 

Robert : pelvic deformity, 483. 

Robertson : fcetal mortality in pelvic 
presentation, 427. 

Roger : albuminuria, 230. 

Rokitansky : puerperal fever, 722. 

Rose, J. M. : prognosis of uterine 
rupture, 555. 

Rotation of foetal head, 405. 
external, of foetal head, 406. 
in face presentation, 419. 
high, 412. 

Round ligaments of uterus, 36. 

Rubeola during pregnancy, 264. 

Rug?e, Penniform, of cervix, 41. 
of vagina, 29. 

Rugby : dilatation of the os, 327. 
passing the hand through the 
placenta for version in placenta 
praevia, 531. 

Runge : alcohol in puerperal fever, 
718. 

Rutter : puerperal contagion, 709. 

Ruysch : hydatidiform degeneration 
of chorion, 190. 

Sacred bone, 5. 

Sacro-coccygeal joint, 5, 8, 9, 11. 
Sacro-iliac synchondroses, 5, 9, 10. 
Sacro-sciatic foramina, 10. 

ligaments, 10. 

notches, 10. 
Sacro-vertebral joint, 5. 
Sacrum, 4. 

articulations of, 5, 7. 

foramina of, 5, 6. 

hollow of, 6. 

mechanical relations of, 8. 

promontory of, 5. 
Saint-Hilaire : monstrosities, 204. 



Saliva, excessive flow of, during preg- 
nancy, 225. 
Salt solution, Subcutaneous injection 
of a, in post-partum hemorrhage, 
577. 
Sanger : Cesarean section, 640. 
Sanger-Leopold operation, 640. 
Saxtorph : mechanism of labor, 401. 
Scanzoni : etiology of eclampsia, 292. 
no lesions in eclampsia, 294. 
hydatidiform degeneration of the 

chorion, 190. 
mortality in prolapse of the funis, 

540. 
fleshy mole, 210. 

forceps and version in pelvic de- 
formity, 498. 
presentation in hydrocephalus, 510. 
changing cranial positions, 414. 
puerperal fever, 723. 
Scarlatina during pregnancy, 265. 
Schaeffer : laparotomy after uterine 

rupture, 560. 
Schatz : brow presentation, 426. 
conversion of face into vertex pres- 
entation, 423. 
power of uterine contractions, 314. 
Schrceder : asphyxia neonatorum, 
586. 
changing cranial positions, 414. 
malacosteon, 485. 
placental delivery, 368. 
method of inducing premature 

labor, 593. 
changes of presentation and posi- 
tion, 402. 
Schiicking : ligation of the cord, 366. 
Schultze : morbid anatomy of as- 
phyxia neonatorum, 586. 
diagnosis of incipient asphyxia, 

587. 
method in asphyxia neonatorum, 

588. 
fcetal heart, 314. 
Schwartz : post-mortem Cesarean 
section, 642. 
foetal heart, 314. 
Scipia Merunia on Cesarean section, 

634. 
Sebaceous glands of vulva, 24. 



764 



Index. 



Secretion, lacteal, Excessive, 689. 

lacteal, Deficient, 688. 
Secretory apparatus of vulva, 24. 
Secundines, Retention of, in abortion, 
165. 

how and when to remove, in abor- 
tion, 178-179. 

management of, in labor, 334. 
Semen, Secretion of, 60. 

description of, 61. 

fecundating power of, 61. 
Semmelweiss : puerperal mortality, 

722. 
Septicaemia, Puerperal, 680. 

puerperal, Prevention of, 725. 
Sex, Diagnosis of, by foetal heart- 
sounds, 124, 125. 
Seyfert : method with placenta prae- 
via, 522. 

puerperal fever, 723. 
Shoulders, Delivery of, 364. 
Sickness, Morning, during preg- 
nancy, 102. 
Signs of pregnancy, 105. 
Simpson : albuminuria in relation to 

insanity of pregnancy, 283. 
Simpson : diagnosis of intra-uterine 
hydrocephalus, 510. 

method with placenta praevia, 522, 
526. 

mortality of placenta prgevia, 520. 

prolapse of the funis, 540. 

puerperal fever, 522. 

version in pelvic deformity, 495. 
Simpson's cranioclast, 627. 
Single-horned uterus, 471. 
Sinuses of ducts of mammary gland, 
55. 

venous, of uterus, 43. 
Sironomeles, 205. 
Skoda : puerperal fever, 725. 
Slawjanski : puerperal mortality, 724. 
Smegma prseputii, 24. 
Smellie: moles, 210. 
Smith, Greig: Cesarean section, 634. 
Smith, Tyler: dilatation of the os, 
327. 

etiology of eclampsia, 292. 

phlegmasia alba dolens, 679. 

version in placenta prsevia, 530. 



Smith, Tyler : cause of uterine inver- 
sion, 582. 
Solayres de Renhac: mechanism of 

labor, 401. 
Southwick, George R. : cephalic ver- 
sion before labor in pelvic pres- 
entation, 435. 
pulse indicative of threatened 
hemorrhage, 653. 
Spermatozoa, Course of, to point of 
fecundation, 62. 
fecundating power of, 61-62. 
duration of fecundating power, 61. 
measurements of, 60-61. 
penetration by, of ovum, 61. 
manner of propulsion of, 61. 
speed of, 61. 
Sphenocephalic foetuses, 206. 
Spiegelberg: induced labor in al- 
buminuria, 237. 
changing cranial positions, 414. 
induced labor in deformed pelvis, 

491. 
uterine rheumatism, 275. 
frequency of vertex presentation, 
401. 
Spinal canal, Termination of, 6, 11. 
Spines of pubes, 4. 
of ilium, 3. 
of ischium, 4. 
Spot, embryonic, Formation of, 65. 

germinative, of ovule, 52. 
Stages of labor, 318. 
Stanesco : mortality in pelvic de- 
formity, 489. ' 
Sternopage, 206. 
Stomocephalic foetuses, 206. 
Stone's short forceps, 606. 
Storer, Horatio R. : Porro's operation, 

644. 
Strangulation from coiling of the 

cord, 201. 
Succenturiatae, Placentae, 74. 
Superior strait, Plane of, 15. 
Sutures, cranial, 82. 
formation of, 82. 
Sycephalic foetuses, 206. 
Sylvester's method with asphyxia 

neonatorum, 587. 
Symmeles, 205. 



Index. 



'65 



Symphyseotomy, 648. 
Symphysis pubis, 4. 
Synadelphe, 206. 
Synchondrosis, Ilio-sacral, 5, 7. 
Syncope during pregnancy, 241. 

a cause of sudden death, 686. 

in relation to phlegmasia alba 
dolens, 679. 
Synotes, 206. 
Syphilis during pregnancy, 270. 

as cause of abortion, 161, 185, 186. 

as cause of endometritis, 185-186. 

of placenta, 195-196. 
Sysomic foetuses, 207. 

Tait,Lawson : Porro's operation, 644. 
Talcott, S. H. : lilium in insanity, 

288. 
Tampon, Vaginal, in threatened 
abortion, 175-176. 
in placenta previa, 524. 
Tanner: abortion as the result of 

albuminuria, 233. 
Tarnier's basiotribe, 628. 

treatment of prolapse of the funis, 

543, 544. 
ligature of the cord, 366. 
rules concerning milk diet, 234. 
puerperium, 724. 
Temperature of lying-in room, 673. 
during puerperium, 655. 
diagram of normal curves, 656. 
Tension, Arterial, of pregnant and 
puerperal pulse, 651, 652, 654. 
as indicative of threatened eclamp- 
sia, 231. 
Testicles in foetus, 78. 
Thermometer, The clinical, 655. 
Thomas, T. Gaylord : knee-elbow 
position in prolapse of the funis, 
543. 
laparo-elytrotomy, 647. 
method of inducing labor, 593. 
Thompson, J. Ashburton : pulse in- 
dicating threatened hemorrhage, 
565, 653. 
Thoradelphe, 206. 
Thorax, formation of, 67. 
Thrombosis and embolism, 678, 686. 
Thrombus of vagina and vulva, 470. 



Tide in its relation to time of labor, 

336. 
Toothache during pregnancy, 243. 
Torsion of the cord, 200. 
Touch, The vaginal, 339, 341. 
Trace, primitive, Formation of, 65. 
Traction force in head-last cases, 497. 
Transfusion, 576. 
Transversus perin?ei muscle, 33. 
Transverse presentation, 442. 

frequency, 442. 

causes, 442. 

diagnosis, 119, 443. 

prognosis, 446. 

unaided termination, 446, 451. 

treatment, 447. 
Trask : condition of ruptured uterus, 

553. 
Traumatism during pregnancy, 244. 
Triocephalic foetuses, 206. 
Trousseau : syphilis, 272. 
Trunk, Delivery of, in pelvic presen- 
tation, 440. 

expulsion of, 408. 
Tubal pregnancy, 143. 

causes of, 143. 

development of foetus in, 144. 

duration of, 148. 

rupture of walls of tubes in, 144. 
Tuberosity of ischium, 4. 
Tubes, Fallopian, 48. 
Tubo-abdominal pregnancy, 141. 
Tubo-interstitial pregnancy, 143. 
Tubo-ovarian pregnancy, 141. 
Tubus medullaris, 66. 
Tuke : insanity of pregnancy, 280. 
Tumors of placenta, 195. 

pelvic and abdominal, obstructing 
labor, 475. 
Tunica albuginea of ovary, 50. 
Turning, 296. 

conditions calling for the opera- 
tion, 596. 

favorable conditions, 596. 

cephalic version, 596. 
before labor in pelvic presen- 
tation, 435. 
during labor in pelvic presen- 
tation, 440. 

podalic version, 598. 



766 



Index. 



Turning, position of the patient, 599. 
combined external and internal 

method, 599. 
internal podalic version, 600. 
completion of the delivery, 604. 
external method, 599. 
for prolapse of cord, 546. 
in pelvic deformity, 495. 
in placenta prsevia, 530. 
in transverse presentation, 449. 
and forceps compared, 497. 
Twin pregnancy, Expulsion of one 
foetus in abortion with, 168. 
diagnosis of, by auscultation, 122. 
locked, 506. 
Twins, 501. 

Typhoid fever during pregnancy, 265. 
Tyre : phlegmasia alba dolens, 676. 
Umbilical cord, Tying and cutting, 

365, 673. 
Umbilicus, Eetraction of, during 

pregnancy, 92. 
Underhill : post-mortem Cesarean 

section, 643. 
Unicornis, Form of uterus, 47. 
Urethra, Length of, from meatus to 
bladder, 23. 
composition of, 23. 
situation of, in vaginal wall, 23. 
Urinary symptoms during preg- 
nancy, 250. 
Urine, Changes in, during preg- 
nancy, 103. 
examination of, during preg- 
nancy, 215. 
retention of, 668. 
treatment, 669. 
Umbilical cord, Formation of, 74. 
non-ligation, 365. 
points for ligature, 364. 
early and late ligature, 365. 
pathology of, 200. 
knots, 200. 
torsion, 200. 
coiling, 201. 
hernia, 201. 
cysts, 201. 
prolapse of, 539. 
frequency, 540. 
prognosis, 540. 



Umbilical cord, Prolapse of, causes, 
541. 

signs of funis presentation, 541. 
has pulsation ceased, 542. 
prevention, 542. 
reposition, 543. 
protection, 545. 
version, 546. 
Uterus, Anatomy of, 34, 35. 

angles, or cornua, of, 35. 

appendages of, Changes in, during 
pregnancy, 99. 

area of, in virgins, 91. 
Uterus bicornis, 47. 

distribution of blood to, 42. 

body of, 35. 
Uterus, Braun's method of treating, 
after delivery, 371. 

cavity of, 37. 

arbor vitse of cervix of, 41. 

cervix, or neck, of, 35. 

cervical canal of, 37. 

mucous membrane in cervical 
canal of, 41. 

change in position of cervix dur- 
ing gestation, 93, 96. 

shortening of cervix during preg- 
nancy, 94-95. 

change in size and texture of cer- 
vix in pregnancy, 93. 

supra-vaginal portion of cervix, 
35. 

cervix of, Vaginal portion of, 35. 

changes in, during pregnancy, 
90-91, 117. 

changes in tissues of, during preg- 
nancy, 38. 

tetanoid constriction of, 467. 

manual compression of, 371. 

congestion of, as cause of abortion, 
163. 

cannon-ball contraction of, 370, 
564. 

contractions of, during labor, 311. 
recurrent, during pregnancy, 108. 

irregular contraction of, as a cause 
of placental retention, 461. 

cordiformis, 47. 

supra-pubic cords of, 36. 

development of, 44. 



Index. 



767 



Uterus, Dimensions of, at different 

months of gestation, 91. 
dilatile and contractile powers of, 

327. 
division of, into parts, S5. 
displacements of gravid, 257. 

anteversions and anteflexions, 
257. 

retroversion, 258. 

retroflexion, 258. 

prolapse, 262. 
double or bifid form of, 43. 
duplex, 47. 
method of emptying, in abortions, 

176. 
external os of, or os tincae, 35. 
fluctuation of, in pregnancy, 111. 
abnormalities in form of, 45-46. 
differences in form of, 34. 
form of, during pregnancy, 91-92. 
fundus of, 35. 
glands of, 41. 

pregnancy in horn of, 145. 
inertia of, 455. 
inclination of, during gestation, 

89-93. 
injections into the, to bring on 

labor, 592. 
inner surface of, after delivery, 

658. 
acute inversion of, 581. 

symptoms, 582. 

treatment, 583. 
involution of, 656. 
involution of, in hydramnios, 199. 
length of, at end of gestation, 91. 
lips of, 35. 
tumefaction and incarceration of 

anterior lip of, 468. 
ligaments of, 35. 
lymphatics of, 44. 
measurements of, 34, 35. 
mobility of, 37. 
mucous surface of, 40, 41. 
of multipara at term, 657. 
muscular fibers, Arrangement of, 

in, 39. 
nerves of, 43. 
relaxation of internal os of, during 

pregnancy, 95. 



Uterus, Peritoneal covering of, 36, 

37, 38. 
venous plexus of, 43. 
polypi of, 473. 

position of, during gestation, 89. 
relation of, to surrounding parts 

during pregnancy, 99. 
treatment of retroversion of, in 

threatened abortion, 174. 
rheumatism of the, 275. 
rupture of, 552. 

seat and character of, 552. 

time of, 552. 

etiology, 552. 

symptoms, 554. 

prognosis, 555. 

treatment, 555. 

laceration of the cervix, 560. 
septus bilocularis, 47. 
shape and size of, 34, 35. 
sinuses of, 43. 

situation of, in pelvic cavity, 35. 
change of situation of, during 

pregnancy, 92. 
size of, at 4th, 5th, 6th, 7th, 8th and 

9th months, 133. 
structure of, 37. 
tissues entering into structure of, 

37. 
subsidence of fundus near end of 

pregnancy, 92. 
support of, 35. 

supra-vaginal portion of, 27. 
unicornis, or single-horned, 47. 
vessels of, 42. 
weight of, 34. 

Vagina, Anatomy of, 26-27. 
appearance of, in pregnancy, 107. 
attachment of, to bladder, 26. 
changes in, 661. 

during pregnancy, 97. 

post-partum, 661. 
columns of, 29. 
contractions of, in labor, 314. 
cul-de-sac of, 27. 
double, or bifid, 47. 
examination per, for diagnosis of 

position, 118. 
form of, 26-27, 



768 



Index. 



Vagina, Laceration of, 560. 
length of walls of, 26. 
lymphatics, 30. 

mucous membrane lining, 27-29. 
mucus of, Reaction of, 29. 
muscular coat of, 27-28. 
orifice of, Location of, 23. 

form of, 23. 
papillae of, 29. 

attachment of, to rectum, 26. 
rugae, or cristas, of, 29. 
sphincter of, 28. 
manner of tamponing, in abortion, 

175-176. 
thrombus of vulva and, 470. 
relation of, to urethra, 26. 
uterine attachment of, 27. 
vessels and nerves of, 30. 
walls of, 26-27. 
Yagitus uterinus, 587. 
Valve, Eustachian, Development of, 

79. 
Van Aubel: Caesarean section, 640. 
Van Huevel: intra-uterine hydro- 
cephalus, 511. 
Varices during pregnancy, 256. 
Variola during pregnancy, 265. 
Vascular area, 65. 
Vectis, The, 620. 
folding, 620. 
uses of, 620. 
Veins, Entrance of air into, 687. 
varicose, of legs during pregnancy, 
100. 
Velpeau : causes of pelvic presenta- 
tion, 428. 
no lesions in eclampsia, 294. 
Vernix caseosa, Development of, 78. 
composition of, 79. 
function of, 79. 
Version, 596. 
conditions calling for the opera- 
tion, 596. 
favorable conditions, 596. 
cephalic version, 596. 
before labor in pelvic presenta- 
tion, 435. 
during labor in pelvic presenta- 
tion, 440. 
podalic version, 598. 



Version, position of the patient, 599. 

combined external and internal 
method, 599. 

internal podalic version, 600. 

completion of the delivery, 604. 

external method of, 599. 

for prolapse of the cord, 546. 

in pelvic deformity, 495. 

in placenta praevia, 530. 

in transverse presentation, 449. 

favorable moment for, 448. 

and forceps compared, 497. 
Vertebrae, Formation of, 66. 
Vertex presentations, 401. 

relative frequency of, 401. 

diagnosis of, 118. 

mechanism of labor in first posi- 
tion of, 403. 

mechanism of labor in second po- 
sition of, 409. 

mechanism of labor in occipito- 
posterior positions of, 409. 

configuration of the head in, 415. 

diagnosis of position in, 416. 
Vesicle, blastodermic, Formation of, 
64. 

germinative, of ovule, 52. 

umbilical, 67. 
Vestibule, Bulbs of, 26. 

composition of, 22. 

glands of, 23, 26. 

opening of meatus urinarius in, 
23. 

mucous membrane of, 23. 

situation of, 22. 
Villi, Amorphous, of chorion, 68. 
Violence, Effect of, on the foetus, 

203. 
Virchow : puerperal fever, 723. 
Vision, Disturbance of, before 

eclampsia, 295. 
Visits, The physician's, after labor. 

668. 
Vitelline membrane of ovum, 52. 
Vitellus of ovum, 52. 
Vitriform body, 67. 
Von Ritgen : episiotomy, 361. 
Volsella, Use of, in abortions, 181. 
Vomiting of pregnancy, 215. 
Vulva, Formation of, 20. 



Index. 



769 



Vulva, Changes in, during preg- 
nancy, 97, 117. 

anterior commissure of, 20. 

posterior commissure of, 20. 

laceration of, Frequency of, 362. 

laceration of, Prevention of, 349. 

immediate repair of lacerations of, 
371. 

secretory apparatus of, 24. 

thrombus of vagina and, 470. 

ways and means for softening and 
dilating the, 358. 
Vulvo-vaginal glands, 25. 

Walker, M. M. : lunar influence on 
parturition, 336. 

Washing and dressing the child, 673. 

Water, Hot, in post-partum hemor- 
rhage, 574. 
in abortion, 181. 

Waters, bag of, Action of, in os dila- 
tation, 328. 
bag of, Rupture of, 329. 

Webster: insanity of pregnancy, 285. 

Wells, Spencer: uterine fibroid ob- 
structing labor, 474. 
(49) 



Wells, Spencer : uterine sutures, 639. 
Wernick : pneumonia during preg- 
nancy, 267. 
Wharton's gelatine, 200. 
White : phlegmasia alba dolens, 676. 
Wigand: metastatic labor-pains, 
316. 
external method of version, 599. 
uterine rheumatism, 276. 
method with placenta preevia, 522. 
Williams, H.: forceps above the 

brim, 495. 
Winckel : thrombus of vagina and 
vulva, 470. 
number of eclamptic seizures, 297. 
Winterburn, Geo. W. : repertory of 

gastric symptoms, 220. 
Wyder : tampon in placenta praevia, 
524. 

XlPHOPAGE, 206. 

Zaglas : movement at sacro-iliac 

articulation, 332. 
Zona pellucida of ovum. 52. 
Zweifel : pelvic deformity, 481. 



mv 







LIBRARY OF CONGRESS 



00DE5T744fl7 



